LIFE & DEATH INTRODUCTION Welcome to Toolworks General We know that the first few days as a surgical resident can be difficult,so we have put together this orientation handout.Use it to familiarize yourself with the layout of TGH and the procedures you will be expected to follow.Refer to the "Operating Procedures Manual" (Below) in any instances that you feel more specific instructions are required.Good luck!!! YOUR RESPONSIBILITES You will be working on eighth floor,under the auspices of the Department of Abdominal Surgery.This is a separate unit with its own personel staffing,record keeping and teaching facilities.As you know,your job is to diagnose patients (after ordering necessary tests),prescribe treatments or drugs and - when appropriate - operate. In short ,you have all the privilages and responsibilities of any other surgeon in the hospital.About the only difference is that Dr. Lindstrom will be tracking you progress and offering guidance when needed. UPON ARRIVAL When you arrive at the start of you shift,the first thing you should do is check in at the Nurses Station.Hospital policy requires that all residents sign in before cases will be assigned.Monica Pierce,the Charge Nurse,keeps track of the sign- in list.Once you sign in with Monica,she will make sure you receive any messages and let you know if you have patients waiting. HOSPITAL PAGING SYSTEM The Health aurthority has installed,at great expense,a hospital message paging system.The paging systems assures that all the physicians can be located immediately so that test results,medical histories and other critical information can be passed to you quickly and efficiently.All physicians (except when in surgery) are required to carry their bleepers and to respond as soon as possible to a page. Failure to respond in a timely manner will result in dismissal from the staff and termination of your hospital privilages. When your bleeper goes off,return as soon as possible to the Nurses Station.Nurse Pierce will relay the message and make a phone a phone available so you can return the call.If you are uncertain how to operate your bleeper,please see the more detailed instructions located in your "Operating Procedures Manual",(See below). THE FLOOR PLAN Aside from the Nurses Station,there are several other areas with which you should become familiar.Across the hall from the Nurses Station is the classroom,where Dr. Lindstrom holds daily lectures (along with special sessions for residents needing extra instruction).The classroom is fully equipped for audio-visual presentations and will become an integral part of your continuing education in abdominal surgery. PATIENT ROOMS The numbered doors at the end of the hall lead to patients rooms.While on duty,you are the attending physician for all patients on the floor.It is your responsibility to look in on the patients and check their progress.An up-to-date medical history for each patient may be found on the clipboard at the base of the patients bed.If you feel additional tests,medication or surgical prep is indicated,mark the appropriate action on the clipboard.See the "Operating Procedures Manual" for more specific instructions on surgery as well as ordering medication and tests. THE PERSONNEL OFFICE Shelly Marks adminsters the personnel office.We recommend that you visit shelly to select you surgical team.You will find that ,while each staff member is skilled and competent,all have slightly different educational backgrounds,experience and personalities.It may take a while to discover the combination of talent and personality with which you feel most comfortable while in the operating theater. THE OPERATING THEATER The double doors to the left of the Nurses Station lead to the operating theater.After surgical prep is ordered,the patient will be brought to the OR when ready. BA GSIC OPERATING PROCEDURES MANUAL GETTING AROUND Getting around the hospital is as simple as clicking on the door you wish to go through.Once inside a room,click on the door to leave.To activate an object,just click on it. SIGNING IN Before you can be assigned any patients,you must inform the hospital staff that you have arrived.Nurse Pierce will offer you the sign-in clip board in the main hall.Click on the clipboard and you will be presented with the sign-in sheet.If you are a new doctor,just type in your name.If you are a returning doctor,click on your name in the "On Duty" box just to the left of your name.To remove or "retire" a doctor,click on the "Retire" box just to the right of that doctors name. DIAGNOSING A PATIENT To diagnose a patient,you should first read the patient's reported symptoms.These symptoms are written on the clipboard you will see at the foot of the patient's bed.Click on the clipboard to pick it up.To put the clipboard down ,click anyware off the clipboard. Tp perform a physical examination of the patient,click on the patients body.You will be presented with a close-up of the torso.To palpate a particular region,simply click on that area.Note the patient's responses.To end a physical examination,click on the bed covers. The patient's clipboard is also used to order a particular treatment or more tests.Just click on the appropriate box.You must put your initials in the space provided at the lower right of the clipboard,in order for the staff to carry out your request.(The initials can be personalized by selecting the "Personalize Initials" option on the Hospitial Guidelines clipboard in the staff room) STAFF ROOM The personnel records,the Hospital Guidelines clipboard and the Honour Roll can all be found in the Staff Room. The nurse you see will offer you a personnel file so that you can select your own operating team.Simply click on the folder she offers you.Choose any two of the six available staff members by putting a check mark in the box next to that persons name.To get more detailed information on any staff member,click on the person's face. In lieu of a menu bar,the Life & Death game settings are controlled from the Hospital Guidelines clipboard,which you will see hanging on the file cabinet.Just click on it to use it. Each new surgeon starts at the beginner level.If you would like a more challenging game,choose the intermediate or advanced play.At the more difficult levels,you will encounter faster bleeders,abnormal EKGs occurring more often and various other aspects of surgery becoming more sensitive,also.The comments by your operating team become less helpful. After choosing your settings on the Hospital Guidelines clipboard.Click in the initials box in the lower right corner. The Toolworks General Hospital Honor Roll is in one of the file cabinet drawers.It displays a list of doctors who have completed both operations. MEDICAL SCHOOL Whenever the chief of of surgery feels that you need schooling.You will will be instructed to report to the medical school.Most of the lessons in the medical school are written on the easel.Turning pages on the easel is done by clicking in the lower left hand corner.The classroom is also outfitted with a slide projector and an automated screen which the chief surgeon uses to explain particularly serious problems.About a half-inch of the screen is visible above the easel,and it is in this area which you should click to lower the screen.Once the screen is down,click anywhere on it to raise it back up. ANSWERING YOUR BLEEPER When Nurse Pierce gives you a message that someone has called,it is in you best interest to return the call.Use the bleeper that came with you Life & Death package to determine the number where they can be reached.Line up the persons name (e.g. Morgan) and where they called from (e.g. Pathology) in the top bleeper window.The correct phone number is contained in the window corresponding to the phone line used for the call.Pick up the phone on the main desk and dial this number.When dialing the phone,you may push the phone buttons by clicking on them with the mouse or you may type the numbers from your keyboard. SURGERY When you first start surgery,the cursor will be in the shape of a hand.Click on an instrument to pick it up.The cursor will change to a representation of that instrument.To put an instrument down,click anywhere on the instrument tray.To use an instrument,move the cursor to the appropriate place and click.For some instruments,such as the scalpel,sponge,suction and antiseptic,you must click and drag the mouse to use them properly. To open a drawer,first put down any instrument you might be holding and then click on the drawer handle.Use the same procedure to close the drawer. When removing forceps or clamps from the patient's body,click on the tool handle. To retract open a tissue layer,pick up the retractor and click near the incision.You will notice that thin strips remain from the previous layer,visible at the top,bottom,left and right of the operating area on the patient.If you click the hand cursor on the left or right strip,you will unretract,or close a tissue layer. There is a button in the lower right corner which allows you to call the chief surgeon directly for help.Most of the time this will allow you to abandon the operation.If you are working on the innermost layer of either operation,however,you will also receive specialized help in medical school from the chief surgeon after you lower the projection screen. QUICK KEYS There are three command keys you can press anywhere in the hospital or anytime during surgery.You can press COMMAND + Q to quit the game.COMMAND + S to toggle the sound on and off. SOME PATHOLOGY AND TREATMENT APPENDICITIS Indications: Appendicitis is the infection and inflammation of the vermiform appendix,a superfluous,finger-sized appendage to the cecum at the junction of the small and large intestine.Appendicitis can be marked by any combination of loss-of-appetite, nausea,vomiting,diarrhea,high fever and acute abdominal pain. Treatment:Surgery is indicated in cases of appendicitis. B BACTERIAL INFECTION:Bacterial infection is the assult upon the body by a bacteria or germ.As the body's defenses attempt to expel the bacteria,certain symptoms manifest themselves.These can include abdominal discomfort,vomiting,diarrhea,high fever and runny nose. TREATMENT:Bed rest and medication are required A INTESTINAL GAS:Symptoms include abdominal pain,generalized weakness and dizziness. TREATMENT:Ovservation and bed rest. C KIDNEY STONES: Small precipitates composed of mineral salts extracted from urine sometimes become lodged in the ducts of the kidneys.The renal calculi can cause extreme discomfort in the lower back and flank area.The stones ,while rarely fatal,are extreamely painful and should appear on an X-ray as small dots above the pelvis. TREATMENT:Kidney-stone patients should be referred to a urologist. D ANEURYSMS:When a blood vessel wall becomes diseased or begins to weaken,the blood vessel begins to dilate (stretch),forming what is known as an aneurysm.Should the artery wall become rough from deterioration,the blood within may clot and form an embolism,further stretching the aneurysm.if the aneurysm occurs in a large artery,the potential bursting of the artery is life-threatening.A particularly dangerous aneurysm occurs in the aorta,the main blood-carrying artery.Aneurysms of the descending ,or abdominal,aorta can often be felt as a pulsating mass in the abdomen.The most common symptom is abdominal pain.Ultrasonic scans reveal aneurysms as solid white lumps. TREATMENT:If a aneurysm swells to ħa dangerous level,5 to 6cm in diameter,the blood vessel's walls must be supported with a drcron graft.Since aneurysms commonly occur in older patients who have less stable systems,surgeons must take care to avoid needless surgery. F ARTHRITIS Arthritis is the erosion of joints and and their surrounding tissues.Arthritis is often found among older patients and can be extreamly painful. TREATMENT:Arthritis is very difficult to treat.The most successful treatments include cautious excerise and pain-relief medication. F DIAGONOSIS:Diagnosis is the study of symptoms in an effort to discover the ailment causing a patients discomfort. This process involves gathering as much information as possible about the patient and his or her symptoms before proceeding with treatment. some of the tools found to be most useful are the patients own report of symptoms,the abdominal exam ,the X-ray and the ultrasonic scan. PATIENTS REPORTED SYMPTOMS: Symptoms reported by the patient provide a starting point for diagnosis.These Symptoms are often written on a clipboard at the foot of the patients bed. ABDOMINAL EXAM The abdominal exam is often an extension of the patients report of symptoms.By palpating the abdomen and listening to the patient,the tending physician can gain a more detailed understanding of the symptoms. To perform an abdominal exam,palpate various locations on the patients abdomen and note the responses.(For more detailed information on examinations ,refer to your Operating Procedures Manual above). X-RAY An X-ray is the image of electromagnetic radiation passed through a body and then captured on film. before it reaches the film below,the radiation passes through porous material,such as skin and muscle, but is absorbed by solid masses,especially bone. X-rays, therefore,show solid masses such as bone but ignore less dense cartilage. ULTRASONIC SCAN: An ultrasonic scan is similar to sonar.During an ultrasonic scan,sound waves are focused on a body and scanned by computer.The recorded wave-forms are translated into images of the masses off of which the sound bounced.Ultrasonic scans show the more porous cartilage that is ignored by X-rays. IN CONCLUSION: After the initial evaluation,evaluation,the physician uses the clipboard at the foot of the patients bed to request treatment or additional diagnostic options.A hospital staff is not allowed to carry out a physicians requests that do not include his or her initials. SURGERY: ORIENTATION: Before a surgeon enters the operating room,he or she must consider the following aspects of surgical procedure: First,he or she must be mentally prepared to finish the operation once it has begun.A medical checklist of the steps involved is after used a preparation.Second,the surgeon must constantly monitor the patients vital signs.Even though the surgical team will help,the main responsibility for the patients well-being is that of the surgeon in charge.Third,every surgeon must be very familiar with the medical instruments he or she must utilize. VITAL SIGNS INTRODUCTION; Several devices constantly report the patients vital statistics during an operation.The electrocardiogram (EKG),clock and blood pressure guage display the primary information. THE EKG:The EKG is an electronic representation of a heart beat and is used to monitor abnormalities in heart operation.Co nditions for which surgeons must be on the alert are Premature Ventricular Contraction (PVC) and Bradycardia. PVC: PVC is thought to arise from an imbalance in the electrical system of the heart,and is characterized by a drop in the EKG line.If not medicated,PVC may lead to Ventricular Fibrillation,characterized by a rapidly modulating EKG line,absent of normal heart rhythm.This condition is usually fatal. BRADYCARDIA: Bradycardia occurs when the heart becomes weak or tired and slows or skips beats.If proper medication is administered,the normal heart rhythm is usually restored.If not,the heart can loose strength and stop beating. BLOOD PRESSURE: The blood pressure guage describes the measure of pressure the heart exerts on the blood vessel walls as it pushes blood against them.It is expressed in two numbers,the systolic pressure,the peak level, measures the maximum pressure of the blood exerted against the vessel walls as the heart contracts.The diastolic pressure represents the force of blood exerted against the walls as the heart relaxes.Blood pressure can drop from prolonged anesthesia or blood loss. SURGICAL CLOCK: The clock displays elapsed time from the start of surgery.Surgeons always work carefully,while trying to avoid unnesessarily prolonging an operation. THE IV BOTTLE: The IV bottle shows the type and remaining quantity of fluid being infused into the patient.IV bottles should not be allowed to empty,since the injection point may become clotted and hinder further IV administration.A steady flow of glucose solution should be administered to the patient even when a specific transfusion is unnecessary. ANESTHETIC:The anesthetic dial displays the status of the anesthetic valve.Generally,if the dial points to "on" ,the valve is open,and the patient is being anesthetized.If the dial points to "off",the valve is closed,anesthetic is not being introduced into the respiration chamber,and the patient is breathing only oxygen-rich air.Making sure the patient is fully anesthetized before commencing the operation is intensely important to any surgeon.The alternative is quite uncomfortable for the patient!. I BASIC SURGICAL TECHNIQUES AND THE ABDOMINAL AREA 1 Here we look at the basic structure of the abdominal cavity and the organs and muscle groups found there.Then,we will discuss the general procedure for surgery in the abdominal area,around which specific operations can be built.Finally,we will look at two surgeries that take place in the abdominal area:the appendectomy and the aneurysm graft.Both surgeries make use of the general procedure as a frame for the particular techniques involved. BASICS OF THE ABDOMEN The human body has several layers of tissue surrounding the skeleton and internal organs.The outermost layer,known as commonly as the skin,protects the body from viral and bacterial infections.The fatty layers underneath,store excess nutrients for later use.Muscles provide strength and structure. TISSUE LAYERS SKIN: The inner vascular,sensitive dermis and dead outer epidermis comprise the skin layer.The skin provides a protective cover that holds the body together. SUBCUTANEOUS FAT Fat is adipose tissue,containing cells distended with oil,that stores excess nutrients for use the body.The subcutaneous fat layer covers the lower frontal abdomen just below the skin. MUSCLE GROUPS RECTUS ABDOMINUS The rectus abdominus is a muscle group just below the subcutaneous fat layer.Known as the sto $mach muscles by lay-persons,the rectus abdominus is characterized by the rippling effect visible across the abdomen. LINEA ALBA:The thin connective tissue between the left and right halves of the rectus abdominus is called the linea alba.It is often incised vertically to provide access through the rectus abdominus to the abdomen. EXTERNAL OBLIQUE:These muscle groups,one on the right and one on the left,cover the sides of the abdominal wall from the bottom of the ribs to the top of the pelvis. TRANSVERSUS ABDOMINUS:Lying just below the external,the transversus muscle tissue connects at the top of the pelvis and the side of the stomach.The muscle cells run at right angles to those of the external oblique. PREPERITONEUM: The preperitoneum is a delicate opaque membranous tissue separating the abdominal muscle layers and the organs of the abdomen. POSTPERITONEUM: This thin membranous tissue,located just below the intestines,covers and protects the kidneys and aorta. ORGANS INTESTINES:One of the major organs of the abdomen,the intestines are responsible for the digestion of food and compacting of waste.The small intestine secretes gastric juices to break down food particles into valuable nutrients.The large intestine compacts waste food material for expulsion. ARTRA: The aorta is the largest artery in the body.It is the major vessel carrying blood to the abdomen and legs.Just below the umbilicus or "belly button",the aorta splits into the left and right iliac arteries which transport the blood to the legs. BASIC SURGICAL TECHNIQUESThe initial and final steps of most surgeries follow a standardized pattern.This procedure can be used as the start and end of most abdominal surgeries. SURFACE PREPARATIONThorough cleansing and proper attire are required in an operating theater.The surgeon must scrub with sterile,antiseptic cleanser,then dress in an approved,sterile surgical gown.The face must be covered with a sterile mask,and a fresh pair of surgical latex gloves must be worn.The patients skin must be similarly prepared.Scrub the uncovered skin with antiseptic and then cover the unaffected regions with sterile drape. INITIAL MEDICATIONSWhen you are ready,add anesthetic to the patients air mixture.Before incising,inject antibiotics to prevent infection after the operation begins.Keep a steady glucose IV dripping to balance fluid loss. INCISING INTRODUCTION The most basic procedure in an operation is the incision and retraction of the top tissue layer.To remove or manipulate an offending organ or appendage,the surgeon must first sever the protective layers which cover it.Since there are numerous levels of tissues,the surgeon must make incisions long enough to allow ample space in which to operate after pulling back the tissue layers. PROCEDURE:The first step in this process is to incise the tissue layer.Generally,this is done with the scalpel.Applying moderate pressure,draw the scapel downward across the layer.Always incise parallel to the muscle cells to insure proper healing. If the layer is an especially thin or delicate one such as the peritoneal layer,raise a bit of the tissue with forceps and nick it carefully with the scalpel.Then use the scissors to continue the incision from the nicking point.This method protects the peritoneal layer as well as the sensitive organs below. CONTROLLING BLEEDERS INTRODUCTION: If the layer is vascular (Containing veins and arteries),it will bleed.The point at which an incision crosses a vein or artery is called a bleeder. These bleeding vessels must be sealed to prevent traumatic blood loss.Use forceps to clamp the bleeders off and temporarily stop the bleeding.Then use either a cauterizer or a ligator to permanently seal each bleeder. CAUTERIZER:To use a cauterizer,place the tip of the cauterizer on the clamped end of the vessel and coagulate. LIGATOR:To use a ligator,encircle the tip of the clamped bleeder with the ligation string and tie off the bleeder tautly. RETRACTING:Once the tissue layer is free of bleeders,it may be retracted.Use the retractors to pull back the incised layer.Slip the blade ends of the retractor into the wound and stretch the tissue apart near the incision.Be sure your incision is long enough before you attempt to retract.If the incision is not long enough , the wound cannot be retracted without damaging the tissue layer. The incise-ligate / cauterize-retract sequence is repeated until the necessary organs or appendages are exposed.Some layers,of course,do not contain blood vessels or arteries,so the ligate / cauterize step is unnecessary. The actual corrective phase of the operations continues at this point. CLOSING THE PATIENT After the operation is complete and you are ready to close the patient,gently release the retractor blades. You must unretract the tissue layers by sliding the retractor blades together and then removing the retractor.At this point,carefully suture the incision closed,so the patients wounds will heal.If you place a suture in an incorrect area,it can be removed with scissors.You must use enough sutures or the wound will not heal.Too many, however, and the tissue may be too corrupted to heal.At the skin level,use adhesive skin strips to close the wound rather than sutures.This helps to reduce scarring. SPECIAL TECHNIQUESIn addition to the general surgical techniques described above,each operation requires the mastery of specific techniques to bring it to completion.The rest of this chapter is devoted to discussions of the apendectomy and aneuryysm grafting techniques. " APPENDECTOMY Introduction The vermiform appendix is located in the lower right quadrant of the patients abdomen. Due to its placement and the form of the musculature in this area, you must use diagonal muscle-split incisions to reach it. ProcedureIncise from the patients upper right to lower left, using what is called a McBurneys Incision, through most of the layers. However, take care not to use McBurneys incisions where it may cause incisions to cross muscle tissue. Make certain when incising the peritoneum, that the colon is not accidentally punctured. After incising and retracting the peritoneum, take a sample of the abdominal fluids, analasis of this specimin will help you prescribe proper medication during the patients recuperation. Use suction to remove the abdominal fluid. Gently lift the cecum from the abdominal cavity until the appendix is free. The appendix is just underneath the cecum. To elevate, clamp the appendix at its tip. The mesoappendix membrane must be incised, and the artery running parallel to the appendi must be tied off and severed before the appendix can be removed. Nick the membrane with the scalpel near the cecum alongside the mesenteric artery. Then tie off the mesenteric artery with a sutere though the nick youve just made. Carefully sever the mesenteric artery fromthe appendix with the scalpel at the tip of the clamp. Because the infected appendix is filled with offencive fluid, it should be clamped off. To do so , place a clamp at the base of the appendix and another slightly higher. Then, sew a draw-string suture between the clamps and sever the appendix. To ensure proper healing of the stump, invert it with your hand and sutere the end of the cecum closed. After, replace the cecum into the abdomen and close the patient. If the appendix ruptures during the surgery immediately insert a drain hose into the appendix and allow it to drain. Aneurysm Grafting Introduction Grafting the aorta is a highly sensetive operation. The aorta is the major blood -carrying vessel in the body. To remove the clot forming dilation and graft the vessel walls, aorta must be clamped off, stopping precious blood flow to the legs. As the aorta remains closed longer, the probability of abnormal heart rythms increases dramaticly. ProcedureBegin the operation using standard incisions and retracktions. The incision at the rectus abdominus most be made on the linea alba . Be sure no to incise the intestines when cutting the preperitoneum.The intestines must be lifted from the abdomen and stabilized with an intestinal bag so that the postperitonium can be incised. Use extreme caution when incising the postperitoneum because the aorta underneath could be peirced. There should be ample room to mobilize the aorta past the postperitoneum. Lay the rubber tubing under the aorta with your hand. An injection of herpin at this stage will keep the blood from clotting and causing embolisms. Carefully clamp the left and right iliac arteries below the anurisim and the mesenteric artery in the middle of the aorta. Finally, stop the blood flow through the aneurysm by applying a clamp just above the aneurysm. Cut the mesenteric artery close to the aorta and ligate it. The aortal incision should be made along the centre of the vessel. This incision must be long enough to remove the clot and insert a graft. Lift the clot from the artery with your hand and insert the dacron graft. Suture the graft ends to the aorta walls, close the aortal incision and suture. The aorta must next be checked for leaks. Release the illac clamps first and then aorta clamp to examine the area for bleeding. If the graft leaks, it will need to be resutered. Finish by demobilizing the aorta and closing the patient. APPENDIX A GLOSSARY Anesthesesia A general anesthetic produces a total lack of bodily sensation and consciousness. A local anesthetic blocks the nerves surrounding an area to be operated on so that the sensation of pain cannot reach the brain. Aneurysm Local dilation or strecthing of a blood vessel due to deterioration, injury or disease of the vessel wall. This condition creates a pulsating mass over which a "murmer" sound can be heard. AntibioticAntibacteirial material, of which penecillin is perhaps the best known, obtained from fungi and bacteria. AnticepticA material, that is destructive to microorganisms that lead to disease, fermentation or putrefaction. Aorta The major artery that emenates from the left ventricle of the heart. Artery A vessel that transports blood from the heart to various tissues in th pe body. ArthritisInflamation of joints and/or the surrounding tissues. Atropine A drug introduced prior to anesthetic to lessen the secretion in both bronchial and salivery systems and to prevent cardiac depresion by quickening the heartbeat. Bacteria Bacteria are a group of microorgasams. The average size of these small cells is approxamatly one micron in transverse diameter. Some are pathogenic (disease producing) to humans. Blood plasma The part of the blood that is composed of liquid, of which 90% is water. Blood presure The blood pressure is the measure of preasure the heart exerts on the blood vessel walls as it pushes blood through them. It is expressed in two numbers, the systolic pressure and the diastolic pressure. The systolic pressure, the peak level, measure the maximum pressure of the blood exerted against the vessel walls as the heart contracts. The distolic pressure represents the force of blood exerted against the vessel walls as the heart relaxes. Bradycardia A retarded rate of heart contraction producing a slowed pulse rate. Calcus An abnormal cohesion of mineral substaces (calculi)that can form in the passageways that transmit the bodys secretions, or in the organs that serve as reservoirs for them. Renel calculi are those located within the kidney. CauterizerAn instrument that uses a heated filament to burn or scar tissuses and thus coagulate bleeding blood vassels. Cecum The roughly 6cm cul-de-sac that lies below the terminal ileum forming the first part of the large intestines. Clamp An instrument used in surgery to grasp,join, compress or support an organ, tissue or vessel. CoalgulateChanging a substance from fluid or gel, to clot. Dacron graft A smooth, pliable plastic tube that is placed within the aorta in order to stablize the artery wall. Dopamine Dopamine is a stimulant used to reverse radicalk drops in blood pressure. Drain The drain is used to siphon offensive fluid from a wound, or in the case of an appendectomy, the appendix. Insert the end of the drain into the incision and let the fluid drain out. Remove the drain when the fluid has been removed. Electtroc -ardiogramThe record made by an electrocardiogragh, an instrument that receives the electrical current produced by a hearts contraction and records it on a moving drum of graph paper or L.E.D display. EmbolisimA solid mass , clot or bubble obstructing a blood vessel Fluid VialA receptacle used to hold a patients bodily fluids often taken during an operation. Foreceps An instrument used for holding seizing or retracting. Gauze A thin, meshed mateirial used in a multitude of surgical procedures. GlucoseDextrose, blood sugar, corn sugar, grape sugar or starch sugar. In this form, carbohydrates are absorbed through the intestinal tract and carried by the blood throughout the body. HeperinA fast acting anticoyugulant drug. IntestinalA receptacle, sometimes called a gut bag, bag used during an operation to hold the intestines out of the way of the surgeon as she or he operates. IntravenusA hollow tube of variable length used to catheter introduce fluids into the body, by way of veins. IV BottleA container for fluid that is fed into the body intravenously (through a vein). Kidney stones Small precipitates, calculi, composed of mineral salts extracted from urine. These stones often become lodged in ducts of the kidneys. LidocaineA local anesthetic recognized as effective as an aniarhythimc agent. LigatorAn instrument used to bind or tie vessels ` that are deep or nearly inaccessible. Lumen The smooth interior of a tube such as an artery or intestine. PalpateTo feel or examine by touch. Pelvis The bony, saucer-shaped cavity that protects the bladder, rectum and reproductive organs. Precipitate A deposit of solid matter that has settled or separated from a solution. PremitureAlso known as PVC, results from the premature Ventriculer contraction of the ventricles(lower chamber Contraction of the heart). This early or weak beat of the heart causes an irregular pulse. Retracktors An instrument for drawing aside the edges of a wound. Saline Relating to or containing salt, salty. Scapel A pointed knife with a convex edge. Scissors Very delicate layers of tissue are cut using scissors. This instrument is often used instead of a scapel because scissors can cut tissues without applying pressure to tender organs underneath. Skin clipsSmall plastic adhesive clips used to hold the skin layer closed after incising. SuctionThe suction is a small vaccuum hose for removing bodily fluids. Deposits of blood or infected fluid can be removed by applying the suction tip to the affected area. Suture The material, often nylon or cat gut, used to unite 2 surfaces of tissue by means a stitch ThrombosisThe formation of a blood clot or clots within the chambers of the heart or in a blood vessel. Utrasonic scan Sound vibrations of high frequency focused into a beam whose echoes provide diagnostic information about the bodys different physical properties. Ventriculer Fibrillation An uncoordinated quivering, as opposed to any kind of sycronized beat, of the hearts ventricles (the 2 lower chambers of the heart). This condition is usually fatal. VermiformSlender and worm like in structure. X-ray Short rays of electromagnetic spectrum that are passed through the body and then captured on photograghic film. X-rays are often used to examine irregularities in skeletal formation.