Page 62 - JSOM Winter 2025

changes from tourniquet release in under 3 hours have been prior to evacuation. No longer prevented by rapid evacuation
studied and considered to be safe in healthy patients, with the times, medically unnecessary tourniquets would carry the risk
caveat that buffering capacity would be reduced in a hypovo- of avoidable tourniquet-related morbidity. This could turn
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lemic trauma patient. From 2015–2020, 11 casualties who minor injuries into ones that cost limbs and lives. Doctrinal
sustained combat-related extremity injury in Mali were treated change through emphasis on tourniquet reassessment is re-
with tourniquets. Each tourniquet was left in place for over quired to reduce the harms of ineffective and medically unnec-
3 hours, leading to complications including rhabdomyoly- essary tourniquets while maintaining the lifesaving benefits of
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sis (11/11 patients), and compartment syndrome (10/11). A rapid tourniquet application.
study of tourniquet use in Ukraine from 2014–2022 reviewed
2,496 patients and found that 92 limbs were amputated when Doctrinal Deficiencies in Tourniquet Management
tourniquet application times ranged from 210–380 minutes.
Seventy-eight amputations were attributed to extensive tissue Tourniquet application is an All Service Member (ASM) skill
necrosis distal to tourniquets in place for more than 6 hours. 9 used to address massive hemorrhage during the care under fire
(CUF) and TFC phases of TCCC. However, once placed, the
ASM TCCC only teaches tourniquet reassessment to evaluate
Battlefield Conditions in Ukraine
their efficacy through lack of distal bleeding or pulse, but not
“Evacuation plans are contingent on the peer being too near,” TC or TO (Figure 1). The Prolonged Casualty Care Guide-
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said Dr. Kasia Hampton describing the current challenges fac- lines from JTS direct ASM and combat life saver (CLS)-trained
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ing Ukrainian medical logistics. Evacuation in Ukraine is Soldiers to “Re-assess all tourniquets and wound dressings.
not comparable to U.S. helicopter transports to surgical care Ensure all bleeding has stopped. If bleeding persists, consider
within an hour. The front line of Ukraine is over 1,000 kilo- additional tightening of tourniquet, or use of hemostatic dress-
meters long with neither side securing air superiority. Ukraine ings with wound packing to stem the hemorrhage.” ASM
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relies on ground and rail evacuation—64% by train, 34% by and CLS levels are not directed to evaluate if the tourniquet is
road, <2% by helicopter —resulting in delays of 4–6 hours. medically indicated. Situationally but not medically indicated
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tourniquets placed during CUF could remain for hours until
Any building that sticks up above the ground is a target for evaluation by a combat medic/corpsman (CMC) or combat
Russian artillery. This has pushed hospitals and aid stations paramedic/provider (CPP) because the lack of arterial bleed-
back from the front line and increased evacuation time and ing due to an effective and medically indicated tourniquet will
distance as well as evacuation platform consideration. Air as- present identically to the lack of bleeding from a non-medi-
sets can be easily shot down, and heavier armored vehicles are cally indicated tourniquet.
easily targeted and contingent on terrain being hospitable. Ini-
tial evacuation may be on foot until sufficiently removed from Conversely, a TO attempt to place a tourniquet 2–3 inches
the front line. Only then can evacuation platforms be used. 10 proximal to the injury, forces soldiers to closely visualize the
site of bleeding versus only “ensuring” efficacy of the high and
In February 2025, Ukraine’s president, Volodymyr Zelenskyy, tight tourniquet by checking tightness and lack of distal bleed-
revealed that 46,000 soldiers had been killed and 380,000 ing. A TC attempt allows even further evaluation to confirm
wounded since February 2022, a rate of over 1,200 fatali- whether a tourniquet is medically necessary via conversion to
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ties and 10,000 wounded per month, noting that 50% of a hemostatic or pressure dressing. Furthermore, Yatsun writes
wounded soldiers return to action. In 2023, the Commander of evaluating tourniquets in Ukraine, “Continued bleeding
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of Medical Forces of the Armed Forces of Ukraine reported due to inadequate tourniquet use occurred mainly after self-
that 36.5% of their casualties had extremity injuries, although application or by other servicemen without the involvement
the severity of these injuries and the tourniquet application of medical professionals.” This speaks to a lack of tourniquet
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rate is not known. Data published by Yatsun in Ukraine re- reassessment skills for non-medical soldiers.
flect a high rate of medically unnecessary tourniquets in line
with the samples from U.S. forces. 4 It should be noted that the training material retrieved from
the Defense Health Agency via Deployed Medicine (Figure 1)
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shows those trained at the ASM level of TCCC should reassess
Implications for U.S. Military
all bleeding control measures including tourniquets via distal
It is impossible to predict the number of casualties in LSCOs pulse. However, the January 2024 TCCC Skill Sets does not
or what evacuation will look like, but it is reasonable to as-
sume that the standard of care may not be the 60-minute FIGURE 1 ASM TCCC Course, slide 28: Circulation/Shock. 14
Golden Hour. Morbidity and mortality from medically unnec-
essary tourniquets will no longer be prevented by short pre-
hospital transport times. The casualty rate could be closer to
what Ukraine has suffered versus the relatively low rate in the
Global War on Terror.

Casualty data over 17 years from Iraq and Afghanistan high-
light the critical role of tourniquet use in saving lives and the
extent to which its importance has been emphasized in De-
partment of Defense (DoD) training. If U.S. LSCOs casualties
2
in have a similar extremity injury rate as Ukrainian soldiers,
approximately 36% of U.S. casualties would be expected to
have tourniquets placed immediately following injury and

60 | JSOM Volume 25, Edition 4 / Winter 2025