GENERAL SURGERY

TASK 1
Patient S., 62 years old, is complaining on acute intermittent pain for a long time
and heaviness in the epigastrium, sometimes heartburn, nausea. According to the
review of radiography the abdominal organs, any pathological signs were not
detected. The abdomen is involved in breathing, soft, moderately painful in the
pyloroduodenal area, symptoms of peritoneal irritation are absent.

ANSWER

1. What method of examination is presented in the figure?

Endoscopic esophagogastric duodenoscopy

2. Describe the pathological changes (which organ, what part of it, the
characteristics of the formation).
We see that it is the enteral part of stomach and that there is a polyp.

3. What is the previous diagnosis?

Polyp of the stomach

4. What should be done with GDS to establish the benign or malignant nature of
the disease?
By doing the esophagogastric duodenoscopy you have to do an endoscopic
biopsy not just from the polyp but also different parts of the stomach.

5. What are the main symptoms of this disease?

Acute intermittent pain for a long time and heaviness in the epigastrium,
sometimes heartburn, nausea. The symptoms are similar to that of gastric ulcer as
well.

6. What additional instrumental methods can be used for diagnosis and why?

Colonoscopy – sometime the polyps could also be in the colon and not just the
stomach

CT scan can be done after the results of biopsy, if any malignancies are detected
in order to identify the location and size of the malignancies

7. What are the most common complications of the disease?

Bleeding & malignancies

8. What are the methods of surgical treatment of the disease?

Endoscopic polypectomy & Laparotomy - resection of the polyp with the wall of
the stomach
If it’s a malignant polyp we could do gastrectomy or resection of the stomach by
Billroth 1 and 2.

9. Indicate possible postoperative complications of the disease?

After endoscopic operation the patient could have bleeding, perforation of the
stomach wall. Laparotomy has similar complications plus peritonitis.

10. What diseases should be differentially diagnosed?

Cancer of the stomach

 TASK 2

Patient C, 50 years old, is complaining on pain in the right hypochondrium,

yellowing of the skin, dark urine, gray stools. Is ill for 2 days, when after an attack
of hepatic colic noted yellowing of the skin and mucous membranes. He has been
suffering from gallstones for a long time. Objective examination: body temperature
37.2 ° C, sclera icteric, tongue moist, abdomen soft, moderately painful in the right
hypochondrium, present a positive symptoms of Kerr, Mussi-Georgievsky, Ortner.

ANSWER

1. What is the previous diagnosis?

Chronic calculous cholecystitis with obstructive jaundice

2. What laboratory test methods should be used?

Complete Blood Count (CBC) to check level of alpha amylase, urine analysis,
biochemical analysis of the blood with bilirubin, AST, ALT, and markers of hepatitis
infection, hemogram

3. What instrumental survey methods should be used?

Initially we could do ultrasound, and fibro gastroduodenoscopy. In some case CT

scan as well as endoscopic retrograde cholangiopancreatography.

4. What diseases should be differentially diagnosed?

Infective hepatitis, tumors (in this location for example tumor of the head of the
pancreas), acute pancreatitis.

5. Which method is shown in the figure. What is the purpose of this study?
The method shown in this image is endoscopic retrograde
cholangiopancreatography. The reason we do this is to do an endoscopic stone
extraction. We remove the stone from the ductus choledochus (aka common bile
duct).

6. Evaluate the pathological changes in the figure.

Size of the common bile duct is more than 1 cm, it should not be more than 0.5
cm. In the common bile duct a lot of stones in the endoscopic retrograde
cholangiopancreatography can be seen near the fibro gastroduodenoscope.
7. Identity the symptoms of Kehr, Mussi-Georgievsky, Ortner on the mannequin.

Kehr's sign - increase of pain with pressure on the area of gall bladder, especially
on deep palpation.
Ortner's sign - tenderness on light percussion at right costal margin by edge of the
hand.

Mussi-Georgievsky sign - stimulation of phrenic nerve which is projected in

supraclavicular area (phrenic sign).

8. Indicate the most common complications of the disease.

Acute biliary pancreatitis and poly organic insufficiency

9. Indicate the methods and scope of surgical treatment.

Firstly, an endoscopic retrograde cholangiopancreatography is done for

endoscopic stone extraction. On the next day a laparoscopic cholecystectomy is
done.

When a endoscopic retrograde cholangiopancreatography cannot be done, a

laparotomy is done with cholecystectomy. After that we locate the common bile
duct and do the incision followed by the removal of all stones as well as external
drainage.
10. Indicate possible postoperative complications.

Acute pancreatitis, hepatic renal insufficiency, pneumonia, myocardial infarction,

and thromboembolism.
 TASK 3

Patient K., 42 years old, went to the doctor with complaints of pain in the left
hypochondrium, sometimes shingles, nausea, dry mouth, diarrhea, weakness,
fever up to 37.6 C°. These complaints appeared after eating a lot of fatty and
spicy foods. He considers himself ill for about 3 years, when for the first time after
consuming a small amount of alcohol and fatty foods, similar complaints
appeared. She was treated by diet and medication. On examination: the tongue is
covered with white plaque, the abdomen is slightly swollen, palpation reveals pain
in the projection of the body and tail of the pancreas, when pressing the points of
Hubergritz, Mayo-Robson.

ANSWER

1. What method of examination is presented in the figure?

Spiral computer tomography with intravenous contrast

2. Describe the pathological changes (which organ, what part of it, the
characteristics of the formation).

Calcification of the body of the pancreas

3. What is the previous diagnosis?

Chronic calculous calcification pancreatitis in acute stage

4. Which changes in laboratory tests are characteristic of this disease?

Leukocytosis – shift of the leukocytosis formula to the left, increase of alpha
amylase

5. Which are the main symptoms of this disease?

Pain in the left hypochondrium, sometimes shingles, nausea, dry mouth, diarrhea,
weakness, fever
6. Which instrumental methods of examination can be used for diagnosis?

Ultrasound of abdomen, CT scan of abdomen with intravenous contrast and

retrograde pancreato cholangiography

7. What are the most common complications of the disease?

Pseudocysts of the pancreas, compression of the common bile duct, obstructive

jaundice, splenic vein thrombosis, and pancreatic cancer.

8. What are the methods of surgical treatment of the disease?

Longitudinal pancreatojejunostomy, cystoenterostomy, and retrograde
cholangiopancreatography to put a stent into the common bile duct (if there is a
complication of obstructive jaundice).
9. Indicate possible postoperative complications of the disease?

Acute pancreatitis, hepatic renal insufficiency, pneumonia, myocardial infarction,

and thromboembolism.

10. What diseases should be differentially diagnosed?

Ulcer disease, chronic calculous cholecystitis, and pancreatic cancer.

 TASK 4

A 40-year-old patient complains of acute pain in the anus, which occurred after
strenuous exercise 2 hours ago. Previously, such complaints were not noted, but
periodically after defecation there is a release of fresh blood. When examining the
anal area, enlarged hemorrhoids, dark purple, painful on palpation are noted at 4,
7 and 11 o clock.

ANSWER

1. How to start a digital rectal examination?

Greet the patient first by saying hello or good day. Introduce yourself to the patient
and ask for consent to do the examination. Wear surgical gloves, lubricate the
index finger with lube.

2. What is the task of finger examination of the rectum?

To assess the condition of the fissures and closing functions of the anal canal

To assess the condition of the mucous membrane of the outlet canal

To determine the state of the agent bodies

To detect the pathological process in the intestine

To assess the nature of intestinal secretion

3. In what position of the patient it is necessary to carry out finger inspection of a
rectum?

Knee-elbow position
4. Gently insert a finger into the intestine to examine all the walls of the intestine.
5. Indicate probable pathological changes during digital examination of the
rectum.
Scarring, cracks, or defects of mucous membrane. Polypoid growths, hemorrhoids
and infiltrates, fistulas and tumors could be palpated.

6. Establish the pathological process in the rectum. See the picture of the
problem.

Hemorrhoids of III or IV degree

7. Analyze possible pathological changes in the intestine in this disease.

Use the finger to go around the intestinal wall in a cycle searching for the shape,
texture, and mobility of hemorrhoids.
8. When removing a finger from the rectum, what pathological discharge should
you pay attention to?

Blood, mucus, or pus

9. What other instrumental methods should be used?

Rectoromanoscopy, irrigoscopy (barium enema), and colonoscopy

10. What type of surgery should be used?

Milligan-Morgan hemorrhoidectomy
 TASK 5

Patient S., 39 years old, is complaining of constant intense pain in the epigastric
and left hypochondrium, vomiting, which does not bring relief. Is ill for 4 days, the
disease is associated with the use of large doses of strong alcohol. Objective
examination: the tongue is dry, covered with white plaque, the abdomen is
moderately swollen, on palpation - tense, painful in the upper parts, positive
symptoms of Mondor, Schotkin-Blumberg. At percussion - blunting on flanks,
auscultatory - peristaltic noises are absent.

ANSWER

1. What is the previous diagnosis?

Acute elementary pancreatitis. Peritonitis.

2. What diseases should be differentially diagnosed?

Perforation of gastroduodenal ulcer, acute cholecystitis, acute intestinal
obstruction, acute aneurysm of abdominal aorta

3. What laboratory tests should be performed?

CBC, urine analysis, alpha amylase of blood, biochemical analysis of the blood for
hemogram

4. What instrumental survey methods should be used?

Ultrasound, x-ray, esophagogastric duodenoscopy and if there is jaundice CT

scan or endoscopic retrograde pancreato cholangiography.

5. Describe the pathological changes in the ultrasound examination

During ultrasound fluid sequestration can be seen in the head of the pancreas and
exudate in the omental pouch

6. What are the main symptoms of this disease?

Constant intense pain in the epigastric and left hypochondrium, vomiting. Positive
Mondor sign, Schotkin-Blumberg’s sign, Kerte’s sign, Mayo-Robson’s sign,
Cullen’s sign, Grunwald’s sign, Grey-Turner’s sign and Chuhrienko’s sign.

7. On the mannequin, identify the Schottkin-Blumberg symptom, Kerte.

Schottkin-Blumberg sign - exert pressure on the area of the abdomen to be

examined and ask the patient whether it hurts, then suddenly raise the palpating
hand after receiving the answer and now let the patient tell you whether it hurt at
the moment of lifting off or what pain was greater.
Kerte’s sign - painful resistance in the epigastric area where the head of the
pancreas is located, 6–7 cm above the navel.

8. Indicate the most common complications of the disease.

Jaundice, poly organic insufficiency, peritonitis

9. Indicate the methods and scope of surgical treatment for aseptic and purulent
complications.

Intensive therapy and minimal invasive methods of treatment and if any

complication are detected we perform laparotomy and pancreato sequestrectomy

10. Indicate possible postoperative complications

Sepsis, poly organic insufficiency, bleeding

 TASK 6

Patient P., 43 years old, complained of paroxysmal pain in the left lumbar region,
radiating to the external genitalia and inner surface of the thigh, fever up to 38.2
C., for 5 days, dry mouth, nausea, repeated vomiting, decreased daily diuresis. In
the projection of the left hypochondrium on palpation: the left kidney is enlarged,
painful. Pasternatsky's symptom is positive on the left. Ultrasound of the urinary
system revealed the spread of the collective system of the left kidney, thinning of
its parenchyma, the ureter could not be visualized, due to significant
pneumatization of the intestine, urine output from the orifice of the left ureter is not
observed.

ANSWER

1. Welcome the patient. Explain the purpose of procedure.

Greet the patient first by saying hello or good day. Introduce yourself to the
patient. The reason why we are doing this examination is because we want to
determine the exact cause of the signs and symptoms displayed by the patient
which will help us identify and diagnose the abnormality or disease for us to treat
the patient.
2. Name the method of radiological examination of the patient. Name the part of
the body (organ) which is examined.
Contrast enhanced computer tomography of the urinary system (kidneys, ureters
and the bladder)

3. Make a conclusion based on the pathological changes.

In the upper third of the left ureter a round shadow of dense consistancy is visible,
obturation of the lumen of the left ureter, cortical thinning of the parenchyma of left
kidney, pyelectasis and hydrocalyx on the left kidney leads us to believe that the
patient has urolithiasis. Stone of the upper third of the left ureter, secondary
hydronephrosis and acute obstructive pyelonephritis.

4. Which are the main complaints of the patient with such disease?
Paroxysmal pain in the left lumbar region, radiating to the external genitalia and
inner surface of the thigh, fever, dry mouth, nausea, repeated vomiting, decreased
daily diuresis

5. Which are the most common symptoms of such a disease?

Paroxysmal pain in the left lumbar region, Pasternatsky's sign positive,
hyperthermia, intoxication, oligouria

6. Which changes in laboratory counts are specific for this disease?

Leukocytosis – shift of the leukocytosis formula to the left, in urine analysis
proteinuria, hematuria, oligocytouria and maybe bacteria in urine.
7. Which other additional methods of examination can be used in diagnostics of
such disease?

Cystoscopy with catheterization of left kidney

8. Name the most common complications for this disease.

Septic shock

9. Name the methods of surgical treatment.

Kidney stenting by cystoscopy with catheterization, nephrostomy, ureterolithotomy
and contact ureterolithotripsy

10. Name the most common post-operative complications.

Acute renal failure, bleeding

 TASK 7

Patient V., 67 years old, complained of urine excretion with blood and shapeless
clots, dysuria. From the anamnesis it is known that hematuria occurs periodically
for 2 years, asymptomatic. It is also known that the patient works in the textile
industry, he is a smoker with 20 years of experience. Ultrasound revealed a
thickening of the bladder wall and the presence of hyperechoic formation of
1.5x1.0 cm in size, with exophytic growth. Excretion of urine from both openings of
the ureters is traced.

ANSWER

1. Welcome the patient. Explain the purpose of procedure.

Greet the patient first by saying hello or good day. Introduce yourself to the
patient. The reason why we are doing this examination is because we want to
determine the exact cause of the signs and symptoms displayed by the patient
which will help us identify and diagnose the abnormality or disease for us to treat
the patient.

2. Name the method of instrumental examination of the patient. Name the part of
the body (organ) which is examined.
Cystoscopy with biopsy of the bladder

3. Make a conclusion based on the pathological changes.

During cystoscopy it was noted on the lateral wall of the bladder below the ureter
there is a single belus tumor. So we conclude it as tumor disease of the urinary
bladder.

4. Which are the main complaints of the patient with such disease?

Hematuria, dysuria, and pain or burning sensation during urination.

5. Which are the most common symptoms of such a disease?

Hematuria, dysuria, and pain or burning sensation during urination, nocturnal

urinary frequency, feeling the need to urinate, but not being able to pass urine

6. What changes in laboratory indicators are characteristic of this disease?

Hematuria, elevated levels of certain enzymes (such as lactate dehydrogenase),

and abnormal levels of proteins in urine

7. Which other additional methods of examination can be used in diagnostics of

such disease?

Ultrasound of bladder, kidneys, ureters. CT with intravenous contrast and MRI.

8. Name the most common complications for this disease.

Bleeding, UTI
9. Name the methods of surgical treatment.

Removal of tumor during cystoscopy the tumor is of small size and does not go
deeper into the bladder wall
In case it is a big tumor we perform urinary bladder resection, after operation
chemotherapy or immunotherapy can also be prescribed

10. Name the most common post-operative complications.

Bleeding, perforation, reoccurrence of tumor

 TASK 8

Patient N., 25 years old, complained of acute pain in the scrotum, its enlargement,
fever up to 37.8 ° C. Physical examination shows: the right half of the scrotum is
enlarged, hyperemic and swollen, the folds of the skin are smoothed. Palpation:
the right epididymis is enlarged in the head and body area, painful, fused with the
testicle; left testicle and left epididymis without visible pathological changes.
Urethral smear microscopy: presence of leukocytes in the field of view.

ANSWER

1. What disease has the patient?

Acute epididymitis

2. Name the method of radiological examination of the patient. Name the part of
the body (organ) which is examined.

Ultrasound of scrotum, testicles, and spermatic cord

3. Make a conclusion based on the pathological changes.

During ultrasound of scrotum, we find increased hyperechoic appendage of the
right testicle the structure of which is homogenous with the presence of reactive
hydrocele.

4. Which are the main complaints of the patient with such disease?

Acute pain in the scrotum, its enlargement, fever

5. Which are the most common symptoms of such a disease?

Acute pain in the corresponding half of the scrotum which increases during
exercise, its enlargement, edema, redness of the skin, intoxication syndrome
6. Which changes in laboratory counts are specific for this disease?

In Urine analysis: leukocyturia, and bacteria in urine. Microscopy would show

presence of leukocytosis with gram negative or positive coccus depending on
etiological factor

7. Which other additional methods of examination can be used in diagnostics of

such disease?

Ultrasound with doppler mapping which would show us the blood flow of the
testicles.

8. Name the most common complications for this disease.

Abscess of testicles
9. Name the methods of surgical treatment.

Organ preserving surgical treatment - dissection of the tunica albuginea of the

epididymis for the compression and at the end of the operation to put the drainage
into the scrotum.

When we have destructive stage epididymectomy is performed.

10. Name the most common post-operative complications.

Bleeding, hematoma and abscess of scrotum

 TASK 9

Patient V., 52 years old, during the last three months noted moderate pain in the
left iliac region, bloating, general weakness, decreased appetite, low -grade fever.
Two days ago, abdominal pain significantly intensified and became convulsive,
stools and gases stopped flowing, and vomiting occurred. The patient's condition
is severe, pulse 102 beats / min., Blood pressure - 100/60 mm Hg. The tongue is
dry, covered with white plaque, the abdomen is swollen, painful to the left
hypogastrium, where a tumor-like formation is determined, there is a symptom of
Sklyarov, Val', Shchotkin-Blumberg. Intestinal motility is enhanced.

ANSWER

1. What is the most likely diagnosis of the patient?

Acute intestinal obstruction

2. What are the main symptoms of this disease?

Cramping pain, lack of passing of gas, bloating, vomiting

3. Which instrumental methods of examination can be used for diagnosis?

Radiography and ultrasound of abdomen, CT of abdomen with intravenous

contrast

4. Specify methods of surgical treatment of the disease.

Laparotomy, intestinal resection, rehabilitation drainage of the abdominal cavity

5. What method of anastomosis should be used in this case?

Side-by-side anastomosis

6. Technique of intestinal suture application

Side-by-side anastomosis is formed by applying continuous double thread suture.

7. Identify the symptoms of Sklyarov, Valya, Shchetkin-Blumberg on the

mannequin.

Sklyarov – splashing sound

Valya – High tympanic sound over the distended bowel

Shchetkin-Blumberg - exert pressure on the area of the abdomen to be examined

and ask the patient whether it hurts, then suddenly raise the palpating hand after
receiving the answer and now let the patient tell you whether it hurt at the moment
of lifting off or what pain was greater.

8. Name the method of decompression of the small intestine

Nasointestinal drainage with Miller apot probe

9. Indicate possible postoperative complications of the disease.

Risk of insufficiency of anastomosis - acute stress, ulcers of small intestine, early
intestinal obstruction, suppuration of the postoperative wound
10. Which diseases should be differentially diagnosed?

Perforated gastroduodenal ulcer, acute pancreatitis and acute cholecystitis, renal

colic
 TRAUMATOLOGY
TASK 3.6
The victim N., 56 years old, was hit by a car. An emergency medical team has
arrived to the traffic accident place. Examination of the patient revealed pallor of
the skin, pulse 68 per min., blood pressure 16,0/10,7 kPa (120/80 mm Hg).
Breathing is independent, free, the abdomen is not painful. There is pathological
mobility and bone crepitus in the middle third of right shin.

ANSWER

1. What is the most likely diagnosis of the patient?

Closed fracture of the shin bones in the middle third

2. What are the tactics and scope of emergency care?

Anesthesia, immobilization of the patient to transport and transportation of patient

to the hospital.

3. Identify clinical signs of limb damage.

Crepitation of fragments, pathological movements of bone fragments

4. Make a conclusion on the revealed pathological changes (dislocation or
fracture).

Closed fracture because of the crepitation of fragments, pathological movements

5. Determine the indications for immobilization. Choose a splint.

“There is pathological mobility and bone crepitus in the middle third of right shin.”
Vacuum splint

6. Prepare the splint for immobilization of the injured limb.

7. Immobilize the injured limb.
8. Remove air from the splint.
9. Check the viability of the limb in the splint.
10. Prepare the victim for further transportation.
TASK 3.4

Solder D., 24 years old, delivered to the first stage of evacuation within 3 hours
after a mine injury of the left upper arm. Physical examination: pale, pulse 115
beats/min, blood pressure 90/160 mm Hg. Locally: a lacerated wound near 6x8
cm of the left shoulder, significantly contaminated by soil, at the bottom of it is
capsule of the shoulder joint without sign of damage. Bleeding is insignificant,
venous. The whole limb is warm, the pulsation in the radial artery is not disturbed,
no disorders of peripheral innervation.

ANSWER

1. Say hello to the patient and introduce yourself, obtain an agreement for
collecting anamnesis and examination.

Greet the patient first by saying hello or good day. Introduce yourself to the patient
and ask for consent to collect the anamnesis and to do the examinations.
2. Collect anamnesis of injury.
3. Make diagnosis.
Mine explosion, gunshot injury, ulcerated wound of the left forearm, traumatic
shock II degree

4. Administer painkiller from syringe.

Administer opioid analgesics subcutaneously

5. Define indications for wound tamponade and immobilization splint.

A lacerated wound near 6x8 cm of the left shoulder, at the bottom of it is capsule
of the shoulder joint without sign of damage. Aseptic dressing by individual
dressing pack and transport immobilization by kramer splint
6. Make tight tamponade of the wound.

Bottom of the wound must be filled with sterile gas, sew the edge of the wound
with ligatures that are tied over the napkins fixing them by a bandage around the
joint and chest

7. Infusion plasma substitutes to restore bleeding.

We need to do venous puncture and start infusion plasma substitution about 1 – 2
liters of plasma
8. Choose a transport splint, prepare it for immobilization by modeling on
yourself.

By using kramer splint

9. Modeled splint is applied on the patient' damaged limb.

Kramer splint is applied to injured limb, starting from forearm to the shoulder of
healthy side

10. Immobilize injured limb by binding splint.

TASK 3.3

Capitan B., 38 years old was delivered to the first stage of evacuation within 1
hour after open injury to his right shoulder, which he received when a car had
exploded on a mine. Physical examination: pale, pulse 115 beats/min, blood
pressure 90/60 mm Hg. Respiration rate 22 per/min. Locally: lacerated wound of
the lateral surface of the lower third of the right shoulder up to 4.5×5.0 cm, with
protrusion of broken humerus. Venous bleeding, pulsation in the radial artery is
not disturbed, the victim canot actively lift up the first finger, lack of sensitivity of
the dorsal surface of the first and second fingers.

ANSWERS

1. Say hello to the patient and introduce yourself, obtain an agreement for
collecting anamnesis and examination.

Greet the patient first by saying hello or good day. Introduce yourself to the patient
and ask for consent to collect the anamnesis and to do the examinations.
2. Collect anamnesis of injury.
3. Make diagnosis.

Mine explosion, gunshot injury, open fracture with displacement of humorous bone
and radial nerve injury, bleeding, traumatic shock II degree
4. Administer painkiller from syringe.

NSAIDs, opioids analgesics if patient needs

5. Apply tourniquet.

Apply torniquet in the upper third of the shoulder with time of application

6. Infusion plasma substitutes to restore bleeding.

We need to do venous puncture and start infusion plasma substitution about 1 – 2

liters of plasma
7. Determine indications for application of individual dressing pack and
immobilization.

Take aseptic dressing by individual dressing pack and transport immobilization of

upper limb by kramer’s splint
8. Tear off the shell of the package, unroll the bandage and apply the pads to the
wound, bandage them.
Kramer splint is applied to injured limb, starting from forearm to the shoulder of
healthy side

9. Choose a transport splint, prepare it for immobilization.

Kramer’s splint

10. Prepare the victim for further transportation.

TASK 3.13

The victim S., 54 years old, had his right upper limb at the level of his forearm
under a circular machine. The skin and visible mucous membranes are pale.
Pulse 136 per min., blood pressure 85-50 mm Hg. The lower third of the forearm
with torn edges in which the tendon fibers protrude, bleeding with! bright red
pulsating jet. Active flexion of II-Ill fingers of right hand is absent.

ANSWER

1. Say hello to the patient, introduce yourself, get consent to collect medical
history and examination.

Greet the patient first by saying hello or good day. Introduce yourself to the patient
and ask for consent to collect the anamnesis and to do the examinations.
2. Collect anamnesis.
3. Establish a diagnosis.
Open wound of lower third of right forearm, traumatic injury of the second and
third finger flex tendons on the right side with injury of radial artery. Arterial
bleeding.
4. Determine the indications for temporary stop of bleeding with using CAT
tourniquet.

The lower third of the forearm with torn edges in which the tendon fibers protrude,
bleeding with! bright red pulsating jet.
5. Wrap the tourniquet's harness strap around the base of the limb and thread its
end through the inner hole of the buckle. Tighten tightly.
6. Pass the end of the belt through the outer hole of the buckle. The movable
buckle will lock the tourniquet in the correct position.
7. Tighten the tourniquet and secure the belt with Velcro®.
8. Rotate the twist rod with both hands until the pulsating stream of blood from
the wound stops and until the pulsation of the artery dorsalis pedis disappears.
9. Insert the end of the twist rod into the locking bracket.
10. Write down the time of applying the tourniquet on it or on the visible part of the
wounded person's body. Before time write down capital letter „T" (tourniquet,
time), which is a signal to medical staff when the tourniquet has been applied
on victim.