THE SURGEON
           
                            README  FIRST


If you have a hard disk, "The Surgeon" can be made to load files much faster.
To install "The Surgeon" on your hard drive, you must first run a program
on the disk entitled "hd_install". To do this, simply open a cli window, 'cd'
to the surgeon disk, and type "execute hd_install". This will copy the entire
program, pictures, and sounds over to the hard drive. You will need about
500K free on the hard drive. Now, any time you wish to play the surgeon,
you need only type 'assign surgeon: dh0:'. Do not boot the original disk
anymore, the entire program is on your hard drive. You may wish to put the
assign statement in your startup-sequence


AMIGA LOADING PROCEDURE:
	To load "The Surgeon" on the Amiga, first boot Kickstart 1.2. Then 
place "The Surgeon" disk in drive 0.  The program will boot automatically.  
For those with external drives, The Surgeon may be booted on drive 1 by 
clicking on the surgeon idon.  "The Surgeon" requires the 1.2 release to 
operate correctly.  Use of 1.1 may create problems during the game.  The game 
requires a machine with at least 512K of memory. (i.e. a 256K machine will 
not be able to run "The Surgeon".)  The game uses many high-res color pictures 
which accounts for its high memory usage.   On a 512K machine, the game must 
be booted from Workbench, and no other applications should be opened.  On 
machines with extra memory,  however, the game may be booted from either CLI 
or Workbench, and other applications may be present.

PROGRAM NOTES:
If you choose to enter your name at the beginning of the program, you may do 
so by clicking in the empty requester box and typing in it.  A default name 
will be given if you do not enter a name.  Click "OK" to continue.

     FORCEPS/CLAMPS:  There may be only 7 Forceps/Clamps on the screen at any 
one time. There is no need to have more than 7.  Also, all Forceps/Clamps must 
be removed before retracting and/or sizing the dratp.  The only exceptions to 
this rule is when retracting open the aorta, the 3 aorta clamps (neck, left 
iliac, and right iliac) may remain in place. Clamps are removed by clicking on 
the inside handle.

     HELP MODE:   Pull down the menu and choose help.  Help is in effect when 
the menu says "Help ON".  When help is on, rectangles depicting valid cutting 
areas are displayed on the screen.  Valid clamping areas are also displayed.

     DIFFICULTY LEVEL:  There are 2 levels of difficulty: Resident, and Surgeon.
These levels may be set on the main menu.  In "Resident Mode", the user is 
informed of any irregular heart patterns, as well as dropping blood pressure.
In "Surgeon Mode", the user must keep a watchful eye on the EKG as well as the
blood pressure status.  Also, complications occur more often in "Surgeon" mode.
Both the Help mode and the difficulty level may be changed at any time during 
the program. (Or any time you feel lost!!)

     SOUND:   When the game boots,  sound will be on.   If you do not wish to 
hear sound, choose the sound option on the menu. Sound may be toggled on 
or off.
When cutting, always make the largest possible cut without going outside the 
operating window or the drape.  The larger the incision, the more you will be 
able to see on the lower levels.  If your incision is not large enough, you 
may not be able to  operate properly on the lower levels.  Also, all incisions 
must be made from the top down.  Any attempt to cut up or to cut outside the 
acceptable areas will result in an "Unacceptable cut!!" message.
After cutting the back wall of the Peritoneum, the game will pause while the 
program loads new images.  This is normal.

If after folding and stitching any 1 of the 3 graft ends you decide to unfold 
it, you will break any stitches placed.  You must replace these with new 
stitches.

Just as in an real operation, you can make many different kinds of mistakes.  
Some mistakes are minor, but others are deadly, such as failure to fully cover 
the patient's exposed area with anaseptic, or forgetting to administer the 
proper drugs at the proper time. Failure to pay close attention to shat you 
are doing can result in the death of your patient and the removal of your 
license!!

Page 3

The "Surgeon" is not just an ordinary game.
It is a simulation game!!.  For those who wanted to be a surgeon, but never 
had a chance, and for the inspired young enthusiasts, the "SURGEON" offers the
opportunity to live through the experience of a real surgeon.  Even the 
terminologies used are authentic medical terminologies.
It is an educational game!!  "The Surgeon" allows you to learn the organs and
layers of the human body while enjoying the fun of the game.  You can also 
understand the procedure, and complications that are seen in a real life 
surgical operation.  The steps involved in this operative procedure are as 
accurate as possible to a real operation of a disease called aneurysm.  This 
can be a valuable assistance to medical students,physicians in training, or 
anyone who wishes to understand the human body and surgical procedures.  Of 
course, the complications are dramitized.  The "surgeon" is not forgiving (i.e.
most mistakes are not tolerated).  In reality, some of these mistakes can be 
corrected. And finally a game itself!!  There are many traps and dangers like 
any other games.  "The Surgeon" is a game of precision and skill.  The whole 
operation depends upon the precision and accuracy of the surgical incisions.  
Many operations are delicate. A slight error and the results can be fatal.
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What are the enemies of a surgeon?

(1) Infection is the number one enemy for any surgical operation.  Many times 
the operation is thought to be successful but only to find out later that the 
patient succumbs to an infection.
(2) Bleeding, Cutting the wrong blood vessels can be dangerous and sometimes 
fatal.
(3) The intestines are usually not clean.  They contain with food and germs 
inside. Cutting the intestines by accident can contaminate the whole surgical 
procedure and can lead to infection.
(4) The time taken to complete an operation is very critical.  The longer the 
operation, the more the complications.
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DEFINITIONS

ABDOMINAL CAVITY:  The abdomen is a hollow cavity, wherein lies the organs 
such as stomach, instestines, duodenum, etc., and blood vessles such as aorta, 
vena cava, other arteries and veins.

AORTA:  The main blood vessel that carries blood from the heart to the rest of
the body.

ANEURYSM:  Dilation and sac like formation of the blood vessel due to weakening 
of its wall. Aortic aneurysm means dilation of the aorta. Aneurysm occurs from 
many causes but mainly due to aging of the blood vessel.  Normally, close 
observation only is needed, but if the size reaches a critical diameter e.g. 
5 centimeters or greater or, if symptoms such as back pain occurs surgical 
operation must be done as soon as possible.  Otherwise, the aorta may rupture.
The result can be fatal.  Because the blood flow is sluggish in the aneurysmal 
sac, there is usually a blood clot, which needs to be removed.  If not removed, 
the blood clot will become dislodged and block the smaller blood vessels.  The 
result can be catastrophic.

ARTERY:  A blood vessel that carries blood from the heart to the rest of the 
body.  The aorta is the main artery.

ARTHRITIS:  An inflammation of the joints.  It usually occurs in the spine and
joints causing stiffness and pain.  The X-rays of the spine with arthritis
shows spaces between the bones to be narrowed and formation of abnormal bone.

BOWELS:  Intestines.  There are two types - large and small.

DUODENUM:  Part of the intestine that lies between the stomach and the small
intestine.

EKG (ELECTROCARDIOGRAM):  An electrical wave pattern that records the
heart beat.  Normal heat beat ranges from 60 to 100 beats per minute.
The longer the surgery the more often the irregular heart beats are seen.
The normal pattern looks like this.....

----/\-----/\-----/\---
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PVC (PREMATURE VENTRICULAR CONTRACTION):  An abnormal EKG impulse that arises 
due to irritability of the heart.  If untreated, can lead to ventricular 
fibrillation.  PVC is suppressed by the drug LIDOCAINE>

--/\---\/---/\---\/---/\---

VENTRICULAR FIBRILLATION:  An irregular heart beat due to irritability of
the heart.  It is very serious and is considered a terminal event unless
immediately corrected.

/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\

BRADYCARDIA:  Another irregular heart beat that results in slowing of the
heart.  When this occurs the heart beat slows to about 50 beats per
minute or less.  If untreated, it results in cardiac arrest where the heart 
stops contracting.  The drug ATROPHINE usually reverses the slowing 
of the heart.

-----/\------------------/\-----------------/\-----

BLOOD PRESSURE:  A measurement of pressure or strain on the blood 
vessel.  A drop in blood pressure occurs from blood loss, prolonged
anesthesia, shift of body fluid contents during surgery or, injury to the
bowel contents, etc.  The longer the surgery takes, the higher the risk of
the blood pressure dropping.  Normal saline (salt water) can
temporarily reverse the drop in blood pressure. DOPAMINE holds the
blood pressure up longer.  A drop in blood pressure from blood loss
can be recovered only by replacement of blood.  A drop in blood
pressure below 70 can lead to an irreversible state of shock.

ILIAC ARTERY:  A blood vessel that supplies blood to the leg.  There are right
and left iliac arteries.

MESENTERIC ARTERY:  A blood vessel that supplies the intestines.
__________________________________________________________________________

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OMENTUM:  An extension of the peritoneum from the stomach and duodenum.
Shaped like a large apron, it hangs down and covers the intestines.

ULTRASOUND:  A machine that looks at different organs by utilizing 
the reflection of the sound wave.  Different organs reflect different
sound wave patterns.  The patterns are then recorded and displayed as a 
picture.

VEIN: A blood vessel that returns blood from the rest of the body to the heart.


VENA CAVA:  A major vein that returns blood to the heart.  Superior vena
cava provides the blood return from the upper part of the body and
inferior vena cava carries the blood return from the lower part of the
body.
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THE INSTRUMENTS AND TOOLS

Scalpel		Ligation
Forceps		Suture
Scissors	Skin clip
Clamps		Blood transfusion
Retractors	Suction
Surgeon's Hand	Saline solution
Sponges		Antibiotics
Sterile Drape	Dopomine
Intestinal bag	Lidocaine
Skin Antiseptic	Atropine
Dacron graft	Heparin
Do sponge count	Scrub

SCALPEL:  A very sharp surgeon's knife used to cut the skin, fat muscles, etc.
There are some cases where it is more advisable to use scissors.
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Incisions must be made from the top to the bottom.  Up to five incisions
can be made for each layer.  However, the best incision is usually a
clean and adequate single incision.

FORCEPS:  Small clamps to stop the bleeding from small blood vessels.
Forceps are also used to lift up peritoneum and other linings.  To release
the forceps, select the forceps icon and then click between the handles
of the forceps.  The blood vessels that are clamped need to be tied and
ligated to permanently stop the bleeding.
There may be only 7 forceps on the screen at any one time.  All forceps
must be removed before retracting and/or sizing the drape.

SCISSORS:  Used to cut the peritoneum or other linings of the body which are
usually very close to vital organs where there is a danger of cutting the
organs underneath (this can occur when the scapel is used). Of course,
a niche or a hole in the linings has to be made first with the scapel.
Usually, the peritoneum is lifted up away from the organ, with the
forceps and a niche is made with the scapel.  The scissors are then
used.  As in the scapel the cut has to be made from above downwards.
The scissors are also used to cut the arteries or veins.

CLAMPS:  Clamps are larger instruments needed to clamp large blood vessels
such as aorta or big arteries.

RETRACTORS:  Retractors are instruments needed to spread the incision area
or to get a better view of the layers beneath and the organs inside.
Just cutting the skin or the muscles will not expose the layers or organs
underneath.

SURGEON'S HAND:  Hand is used to move or mobilize the organs, to
push duodenum away, to mobilize the aorta and to remove the blood
clot.

SPONGE:  Sponges are used to wipe excess blood for a clean view.  When the
sponge changes its color (i.e. soaked with blood), you must click the
sponge icon again to get another clean sponge.  The surgeon must keep
track of the number of sponges used.

DRAPE:  This is a sterile drape used to cover parts of the patient's body not
involved in the operation.  Hold down the button, while in the operating
field to "size" the exposed area in the drape.  Drape is used to prevent
contamination with germs during operation.

INTESTINAL BAG:  After mobilizing the bowel and intestines to keep them out
of the way, it is better to keep them in the bag to prevent them from
falling back into the body cavity
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ANTISEPTIC SOLUTION:  Normally, the patient's skin is covered with germs
and bacteria but the body cavity inside is totally free of germs.  The
surgeon needs to clean up the skin throughly with the antiseptic
solution before entering into the body cavity.

DACRON GRAFT:  The graft is made of a synthetic material, and is used to
replace the damaged part of the aorta.  This creates a smooth functioning
lumen for the blood flow.  Click the cursor in the anterior half to fold the
anterior wall over for stitches.

                            ! -------posterior half
                             O!-------anterior half
                            !  !
                            !  !
                           /    \
                          /  /\  \
          anterior half-- O      O
                          \     /
                              !
                      posterior half

SPONGE COUNT:  Each time you use a sponge, you need to keep track of how
many sponges being used.  Many times a sponge is left behind in the
abdominal cavity.  Sponge count is usually done before closing the
abdomen.  Click the icon-sponge count and answer the question.

LIGATION:  The clamped bleeders need to be tied with the ligation before the
forceps are removed, otherwise they will bleed again. To ligate (tie) the
vessel, click the ligation icon and then click the mouse at the bleeders.

SUTURE:  The sutures are used to stitch the organs and linings of the abdomen
except the skin.

SKIN CLIP:  The skin clips are usually used to close the incision in the skin.

BLOOD:  A drop in blood pressure from blood loss is controlled best by a blood
transfusion.  There is a danger of reactions to blood transfusion,
particularly if too many blood transfusions are given.  Therefore the
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number of blood transfusion that can be given is limited to three.

SUCTION:  Larger amount of blood is removed more quickly by suctioning. It
can only be used for bleeders inside the body.

SALINE SOLUTION:  A salt solution that temporarily raises the blood
pressure.  Because the effect is usually transient, the number of saline
solutions that can be given is no more than three.

ANTIBIOTICS:  The operation involves opening of clean and delicate organs.
Antibiotics are usually given at the start of the operation.

DOPAMINE:  This medication is used to recover the drop in blood pressure.
The effect lasts longer.  In the game, the dopamine can be used only
once.

LIDOCAINE:  This medication should be used only for the PVC's.  Using
lidocaine for other irregular heart beats can be dangerous.

ATROINE:  The medication is used only for slow heart beat.  Using atropine
for other iular heart beat can be dangerous.

HEPARIN:  heparin is a medicine used to prrent clotting of blood.  Heparin,
should be used before clamping the aorta.

SCRUB: The first thing a surgeon must do before any operation is to scrub i.e.
clean his hands throughly!!
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THE LAYERS OF THE ABDOMEN
----Skin
----Subcutaneous Fat
----Linea Alba
----Preperitoneal Fat
----Peritoneum
----Intestines
----Posterior Peritoneum
----Duodenum and Aorta

To reach to the aortic aneurysm, we need to understand the layers of the
abdomen that we have to go through.
1.  SKIN - Every body knows what skin is.
2.  SUBCUTANEOUS FAT - A layer of fat.
3.  LINEA ALBA - A layer of fat.
4.  PREPERITONEAL FAT - A thin layer of fat stuck to the peritoneum that
    needs to be scraped delicately-usually with a scapel-to get better access
    to the peritoneum.  The bowel underneath may be cut if undue pressure
    is placed while scraping the preperitoneal fat.
5.  PERITONEUM - A smooth thin sheath that surrounds the organs such as
	stomach, duodenum, intestines etc. Imagine a balloon in which lies the
	organs.
6.  Then comes the organs which you must move away to expose the posterior
	part of the peritoneum.
7.  PERITONEAL FAT - Another thin layer of fat that needs to be scraped
	away delicately with a scalpel.
8.  POSTERIOR PERITONEUM - A thin sheath that covers the aorta.  Imagine a
	posterior wall of the balloon.
9.  Finally comes the AORTA and the other blood vessels.  The DUODENUM, a
    part of the bowel also lies underneath the posterior peritoneum. It needs
	to be moved away for a better view.
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AMIGA LOADING PROCEDURE:

To load "The Surgeon" on the Amiga, first boot Kickstart 1.2, followed by
Workbench 1.2  "The Surgeon" requires 1.2 release to operate correctly.  Use
of 1.1 may create problems during the game.  The game requires an Amiga with a
minimum of 512K memory.  The game uses many Hi-res color pictures which
accounts for its high memory usage.  The game must be booted from Workbench,
and no other applications may be opened.  On machines with extra memory,
however, the game may be booted from either CLI or Workbench, and other
applications may be present.
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TO PLAY THE GAME.....

One day Mr. Jones comes into your office for a checkup.  While examining
him, you suspect an aortic aneurysm.  Since this can be a portentially fatal
problem requiring major surgery, you must determine through a series of x-rays
and ultrascans whether an aneurysm actually exists or not. Unfortunately, other
diseases such as arthritis often prduce similar symptoms.  If an operation is
performed unnecessarily, the dangers of complications exist as does the chance
of the patient dying.  On the other hand, if the surgery is not performed when
needed, there is a danger of the aneurysm bursting.  The result is fatal.
After the decision (hopefully the right one) is made, the operation begins.This
is where your skill and experience as a vascular surgeon comes in...
First, the surgical area needs to be cleaned and free from infection. The right
instrument must be used at each stage of operation.A majority of the incisions
are midline and from top to bottom.
The operation is delicate and care must be taken not to accidentally cut other
blood vessels and organs. On the other hand, the aorta and the branches need to
be clamped before the aneurysmal sac is opened.  The mesenteric artery must be
clamped, cut and ligated.  Of course, the aneurysm has to be mobilized (lifted
up) first to be exposed.  The aneurysmal sac sometimes has a blood clot inside
which needs to be removed and heparin (a blood thinner) is usually given to
prevent new blood clot formation.  The new blood clot can becomes dislodged
and block the blood vessels in the legs.  The result can be detrimental.
Since the wall of the aorta is thin and baggy, a graft must be placed to 
recreate a smooth lumen.  Suturing the graft to the blood vessel wall has to 
be correct.After the graft is in place, all the organs must be replaced and 
the walls closed and sutured.
Throughout the operation, the EKG monitor and blood pressure need to be
watched closely.  Of course, keeping track of the number of sponges, forceps
and clamps that are used is also very important.  You do not want any of them 
to be left behind!!!
Nothing is more rewarding than performing a clean and successful operation
and saving a patient's life.
                                    BEST OF LUCK !!!
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----Spine bone
----Space between
      two bones
----Hip bone

             X-Rays
          
             back of patient
Gall 
Bladder--                       -- Aorta
Vena Cava--                  
                                      ---Spine
           front of patient

ULTRASONIC SCAN
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                            ---aorta
                                 neck
duodenum--
Inferior
vena cava--
mesenteric
artery--
left                       right
iliac                      iliac
artery--           ---artery

NORMAL AORTA

                   ---aorta neck
duodenum--
inferior 
vena cava--

mesenteric                    ---aneurysm
artery---
left                                   right
iliac                                  iliac
artery--                        --artery

              ANEURYSM
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This is the actual step by step sequence necessary.  Only read this if
you confess that you can never be a surgeon.
(Even though the steps are explained, the explination still does not prevent 
the complications that can occur.  It is up to you to make sure it will never 
happen).
> Scrub
> Administer antibiotics.
> Paint abdomen with antiseptic solution.
> Cover abdomen with sterile drape.
> Incision of skin with scalpel. (midline incision from above downward).
> wipe blood with sponges (clamping with forceps without wiping is easier, if 
bleeding is not excessive)
> Bleeders must be clamped with artery forceps, then ligated.
> Retract skin (Remove all forceps first).
> Incision of subcutaneous fat with scalpel.(midline incision from above 
downward)
> Retract subcutaneous fat.
> Control bleeding as before.
> Incision of linea alba (midline incision from above downward)
> Retract linea alba.
> Scrape preperitoneal fat with scalpel i.e. move the scalpel right and left, 
for just a short distance
> Section of peritoneum wall at the top is elevated with forcep.
> Elevated section is nicked with scalpel.
> Full incision of peritoneum wall with scissors starting at nick.
> Remove forcep.
> Retrace peritoneum.
> If small intestines were cut, clean with sponge and suture the cut.
> Move small intestines out incision with hand.
> Put intestines in intestinal bag.
> Postperitoneal fat is scraped away with scalpel.
> Section of posterior peritoneum wall at the top is elevated with forceps.
> Elevated section is nicked with scalpel.
> Full incision of peritoneum wall with scissors (above downwards)
> Remove forcep.
> Retraction of posterior peritoneum wall.
> The duodenum is pushed up with hand.
> The anuerysm is mobilized with hand.
(Rubber tubes are looped around the aorta, and the two common iliac arteries
above and below the aneurysm)
> Inject heparin
> Clamp the iliac arteries below the aneurysm FIRST.
> Clamp aorta neck above the aneurysm.
> Clamp inferior mesenteric artery at it's root
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> The inferior mesenteric artery is cut and ligated near its root (If you are
having difficulty, try to click along its course near the root).
> Remove clamp from inferior mesenteric
> The aneurysm is incised (midline incision)
> Aneurysm is retracted open.
> Clot is removed from anurysm by hand.
> The two lumbar arteries in the back of the aneurysm must be clamped and
ligated
> The graft is inserted
> The aorta neck is sutured. Apply at least five stitches to the top edge of 
the graft neck. Then click the needle on the bottom edge of the graft neck to 
fold it over. Finally apply five stitches to the now top edge.
> The two illiac branches are sutured the same way
> The clamps are removed
> Unretract aneurysm (remove the retractor)
> Suture aneurysm
> Unmobilize aneurysm with hand
> Unretract posterior peritoneum
> Sutured posterior peritoneum
> The intestines are replaced with hand
> Unretract preperitoneum
> Suture preperitoneum
> Unretract Linea alba
> Linea alba is sutured
> Skin is closed with skin clamps
           Operation is finished.

