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evidence-based medicine while still accounting for tactical re- We will not summarize widely available guidelines. It is not the
alities of combat. It is said that “good medicine equals bad tac- authors’ intent to criticize the practices of Ukrainian military
tics”; however, bad tactics can result in greater morbidity and and civilian personnel, who have demonstrated an exceptional
mortality, leading to mission failure. As understood by these ability to adapt to an evolving landscape and have extensive
leaders, a system to revolutionize battlefield medicine must bal- expertise in caring for casualties. Our aim is to explore the
ance mission, tactical realities, and evidence-based medicine. effects of the implementation of these TCCC concepts in the
Ukrainian war through case reports that collectively highlight
Tactical Combat Casualty Care (TCCC) guidelines recom- major identified gaps contributing to higher complication
mending increased tourniquet use in tactical situations were rates. These gaps include prolonged evacuation times, major
13
developed and adopted by many SOF units. In 1999, the systemic differences, and variation in medic training.
75th Ranger Regiment instituted a mandatory training policy
1,9
for all Servicemembers. A major conflict with casualties pro- We intend to provoke a robust discussion on the risks of di-
vided an opportunity to fully assess the performance of TCCC: rectly implementing guidelines outside of the systems in which
Afghanistan and Iraq, also referred to as the Global War on they were validated. We advocate for an objective discussion
14
Terrorism (GWOT). SOF units utilizing TCCC and the DoD to modify current status, both to better serve those affected by
relying on traditional paradigms served as a study and con- this war and to effectively prepare partner nations in future
trol group. Comparative data from 2001 to 2010 showed SOF near-peer conflicts. This will be best achieved by revisiting the
units decreased preventable mortality (0%–3%) as compared teaching approach of core TCCC concepts and considering
with conventional forces (9%–24%). 1,2,15–17 To further target how tourniquet conversion is approached in guidelines. Re-
ongoing identified gaps, military leaders formed the CoTCCC cent steps taken to address these issues and promote solutions
to implement near real-time updates to guidelines based on will be summarized. 21
evidence collected through a Joint Trauma Registry (JTR). In
1,2
2005, all Servicemembers were required to carry tourniquets, Cases
and within one year their use was ubiquitous on the battle- The Temple University Institutional Review Board deemed
field, supported by evidence that prehospital application was this not to be human subject research. Clinicians provided ob-
superior to in-hospital application. 7,18 Survival rates reflected servations from observed patients after the fact, and all cases
a 67% decrease in mortality from limb hemorrhage without were de-identified.
a significant increase in morbidity. By 2012, it was estimated
that tourniquets alone saved approximately 2,000 lives in the These cases were chosen from several reports of sources car-
GWOT. 5,6,9,19 ing for patients at or near the point of injury (POI) and are
de-identified to protect the personal and operational secu-
TCCC concepts led to the highest survival rates in modern rity of those involved. Details may have been intentionally
combat. 1,3,15 A paradigm to maximize the ability of tourniquets removed or obscured. Of note, documentation of tourniquet
to decrease mortality without increasing morbidity had finally times is, according to many reports, inconsistent and often not
been realized. These concepts were embraced and adapted carried forward in medical records. All cases occurred between
internationally by allied nation militaries. In the first decade March 2022 and July 2023.
of the twenty-first century, NATO made tourniquets a stan-
dard item for all personnel and standardized training for both Case 1 (direct patient encounter): An adult male presented
conventional and SOF personnel. With civilian entities such with fragmentation injuries to the right lower leg resulting
as Stop the Bleed, Tactical Emergency Casualty Care (TECC), from a drone strike. A non-medic Servicemember placed a
and Prehospital Trauma Life Support (PHTLS) adapting tourniquet directly above his knee within minutes at the POI.
TCCC guidelines for the prehospital setting, a global gener- The casualty stated that after approximately 4 hours, person-
ation of soldiers and medical personnel advocating for tour- nel he identified as a medic reached the scene, checked the
niquet usage and training without hesitation was created. 5,20 tourniquet, and placed a second tourniquet proximally near
the inguinal region. Approximately 6–8 hours after injury, he
The life-saving potential of tourniquets is undisputed, but the stated, he was evacuated and transported to a trauma stabili-
inherent risks of increasing morbidity and mortality still exist. zation point (TSP), where both tourniquets were removed and
The potential sequelae range from minor reversible compli- damage control surgery (an external fixator to the right lower
cations such as paresthesias to rhabdomyolysis, amputation, extremity) was performed. At the time of transfer to a surgi-
and death. Unknown to date is what occurs if similar guide- cal hospital in a nearby city, approximately 14–18 hours from
6
lines are implemented in a less-standardized system and/or in the injury, he had palpable limb pulses but was persistently
a conflict with different tactical realities. The large-scale inva- oozing venous blood from his wounds. The lower extremity
sion of Ukraine since February 2022 provides an unfortunate, was grossly edematous and discolored below the knee, con-
yet valuable, opportunity to explore the performance of these sistent with compartment syndrome. Follow-up records were
concepts in a near-peer conflict. An overwhelming amount of not available.
evidence has emerged indicating that despite their life-saving
potential, tourniquet practices have also resulted in signifi- Case 2 (report from medical personnel at CCP): Following
cant morbidity, mortality, and drain on downstream medical a large artillery strike, seven casualties arrived at a casualty
system resources. TCCC concepts have been taught by many collection point (CCP) that was staffed by non-governmental
training entities ranging from partner nations to non-govern- organization (NGO) medical personnel, including a former
mental organizations (NGOs). Laypeople, volunteer forces, military medic. All seven casualties had had limb tourniquets
armed forces, and civilian medical personnel have all been the placed prior to arrival. On further assessment by the medic,
recipients of training. The authors of this paper have been a six casualties, all awake and alert, were found to have only
part of these efforts in varying roles. superficial limb wounds and no clear medical indication for

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