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germane to all conflict realities. We propose the following im- piece of equipment kept on one’s person that can be used by
mediate steps: anyone, civilian or military, while living under constant threat
in an active conflict should be acknowledged.
1. A revisited commitment to training the full spectrum of
TCCC concepts. All entities conducting training in this The founders of TCCC were well aware of tourniquet risks
war should stress the full breadth of best practices in all and accounted for them during the development of the guide-
trainings, including CUF versus TFC, appropriate tour- lines. Their success is reflected in the all-time low potentially
niquet application in CUF (emphasizing identification of preventable mortality, without significant increase in long-
life-threatening hemorrhage), continuous reassessment of term morbidity, during the GWOT. Training resources, a multi-
tourniquets, appropriate attempts at conversion, and an tiered system of medical care, including rapid evacuation to
understanding of alternate methods of hemorrhage con- high-level medical care, and macro-level tactical superiority all
trol. Recognizing that de-emphasizing tourniquet applica- factored into the successes of tourniquets.
tion in combat can increase mortality, we do not advocate
any changes to guidelines recommending the application Ground truths in current or future near-peer conflicts will be
of tourniquets. However, avoiding placement of non- more complex than during the GWOT. As Shackelford and
indicated tourniquets may significantly decrease morbidity Drew predicted, in a conflict with prolonged evacuation times
in prolonged evacuation times. Teaching of these principles and limited medical assets, failure to reassess and convert tour-
should occur over an appropriate time frame and include niquets in a timely manner would lead to prolonged ischemia
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theory, scenario-based learning, and hands-on practice, ide- and “avoidable loss of extremity.” This reality is manifesting
ally utilizing high-fidelity simulation models when possible. in current-day Ukraine.
Training, which should be conducted by subject matter ex-
perts, must stress basic skills including patient assessment The foundation of TCCC rests in simple, protocolized man-
and reassessment, basic hemorrhage control techniques, agement based on best-practice medicine and accounting for
and appropriate timing of TCCC skills. Training and teach- the tactical realities of conflict. However, as with all guidelines,
ing materials should be standardized under relevant au- the context in which they are used and differences in systems
thorities to deter unauthorized materials and approaches must be considered; the concepts cannot be merely translated
taught by non-SMEs. The most important aspect to revisit and deployed as though the systems are parallel. If the reality
is TCCC as a guide, not a protocol. Guidelines need to ac- on the ground and/or system results in significant evacuation
count for the realities of ground combat and the greater delays and does not allow for the training or execution of
trauma system in place. The available literature regarding TCCC concepts as refined during the GWOT, then they must
tactical medical care, to include TCCC, should be utilized be adapted to new ground truths. Without this evolution, data
in creating the best care guidelines for a given tactical suggest that a return to the age-old paradigm of tourniquet
reality. use only after other methods of hemorrhage control fail could
2. Revisiting the role of tourniquet practices in guidelines. be preferable to liberal tourniquet use. With appropriate inter-
When adapting the evidence-based best practices that vention, this devastating outcome is avoidable.
TCCC is founded upon, care must be taken to consider the
system and ground truths in order to responsibly adapt the The collective network of medical, military, government, and
knowledge into appropriate guidelines. Rigid protocoliza- NGO sectors must collaborate to identify actionable inter-
tion may reduce flexibility and limit the ability of operators ventions that can be executed in a timely fashion, taking into
to adapt to ground truths. As referenced by many subject account both the realities of the war in Ukraine and future
matter experts cited in this paper, tourniquet assessment near-peer or peer-peer conflicts. Although difficult to gather
and conversion were not skills emphasized in the GWOT during an active conflict in a stressed system, and only with
era. Consideration should be given to the fact that a critical support from the partner nation, data must be gathered to ob-
threshold of combat medics near the POI may be difficult to jectively define best practices.
achieve. The recent modification to TCCC to include con-
version/replacement as a skill taught to combat lifesavers, Acknowledgments
if reflected in guideline adoption and approach to training The authors acknowledge the assistance of Jennifer Gurney,
in Ukraine, may relieve the burden previously placed on the MD, James Stone, MD, Warren C. Dorlac, MD, Jonathan
presence of medics. By offering a platform for expeditious Vinke, Ferdinand Hofer, MD, and Michael Hetzler in the
changes, appropriate adaptations made through entities preparation and revision of this manuscript.
such as CoTCCC may aid and inform internal progress.
Any proposed changes must consider the body of evidence Author Contributions
that tourniquets without medical indications will occur at JP and MT conceived the study concept. JP, MT, SD, TB, and
high rates even with highly trained operators and be realis- LR, LS obtained case studies. All authors wrote and/or edited
tic about the likelihood of similar or higher rates depending article text. All authors read, edited, and approved the final
on training standardizations. manuscript.

Disclosures
Conclusion
JP, CR, and FS are consultants for Global Response Medicine.
Tourniquets are justly embraced as a life-saving intervention. AL is an employee of Global Response Medicine. KW holds
As an international community, we have effectively moved past equity in Precision Trauma LLC. JH is Co-founder, member
the era when tourniquets were referred to as “an instrument of the and Board of Directors, and equity holder in Decisio
of the devil that sometimes saves a life.” Additionally, the Health; a consultant for WFIRM and Aspen; and sits on the
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importance, whether real or perceived, of having a life-saving Boards of Directors of and is an equity holder in CCJ Medical
24 | JSOM Volume 23, Edition 1 / Spring 2024