Tens of thousands of Ukrainians have lost their limbs during the Russian invasion of Ukraine. Photo credit: President of Ukraine / Public Domain.
In the fog of war, life-saving tools can become double-edged symbols of survival. In Ukraine, battlefield surgeons are sounding the alarm over the widespread misuse of tourniquets, devices meant to control bleeding but increasingly linked to preventable limb loss and fatalities. They’ve dubbed the phenomenon the “cult of tourniquets,” a stark reference to the overreliance on these devices. With prolonged application often exceeding safe limits due to evacuation delays and minimal training, experts estimate that tens of thousands of amputations could have been avoided with better protocols and more context-aware trauma care.¹
Originally introduced as a battlefield necessity, tourniquets are designed to staunch arterial bleeding in limbs. Their successful deployment in Iraq and Afghanistan, where rapid evacuation minimized risks, cemented their place in Western military doctrine.² But Ukraine isn’t Iraq, and time is no longer on the side of the wounded.
The Reality on the Ground
In Ukraine, battlefield evacuations often take six hours or longer. This delay stems from constant drone surveillance, lack of air superiority, and treacherous terrain. That delay turns tourniquets, which should only be in place for 60–90 minutes, into instruments of ischemia, rhabdomyolysis, kidney failure, and limb loss.³
Surgeons are encountering patients with limbs that are “unsalvageable not due to injury, but to the device meant to save them,” says Captain Rom A. Stevens, a retired U.S. Navy medical officer.¹ Of Ukraine’s estimated 100,000 wartime amputees, Stevens believes as many as 75,000 lost limbs due to prolonged or unnecessary tourniquet use, often applied by minimally trained personnel or civilians operating under panic and misinformation.¹
Tourniquets are the primary intervention for arterial extremity hemorrhage when other methods (e.g. pressure dressings) are not feasible under fire. While prolonged tourniquet application carries risks, its value in life-threatening scenarios cannot be overstated. In arterial extremity hemorrhage, often the case under fire, tourniquets remain the sole effective measure to prevent fatal blood loss.
Protocols Misapplied
Ukraine’s emergency responders use the U.S. CoTCCC (Committee on Tactical Combat Casualty Care) Guidelines, developed for battlefield conditions that assume rapid medevac and professionally trained medics.² However, in the Ukrainian theater:
- Evacuation is delayed
- Medics are often absent
- Tourniquets are left on for hours, even days
What worked in one war, with helicopters ready and medics on hand, is maiming survivors in another, where the wounded wait in trenches under drone surveillance.
The Human Cost
Behind the statistics are young Ukrainians whose futures have been altered irrevocably. Soldiers returning with amputations face not only physical and emotional trauma, but often renal failure requiring dialysis, a burden for both individuals and Ukraine’s healthcare system.³
Tourniquets Save Lives When Used Properly
While battlefield misuse is a serious concern, it’s essential not to discourage the use of tourniquets in civilian emergencies, where they remain one of the most effective tools for stopping life-threatening bleeding.⁴
Programs like STOP THE BLEED® emphasize that:
- Tourniquets can be applied in under a minute to control hemorrhage from limbs⁴
- They are especially critical in mass casualty events, car accidents, workplace injuries, and active shooter situations
- Studies show that 20% of trauma deaths could be prevented with rapid bleeding control, including tourniquet use
- When applied correctly and removed within 1–2 hours, the risk of complications is minimal⁴
The key is education and context. Knowing when and how to use a tourniquet can mean the difference between life and death.
A Call for Change
Surgeons and trauma specialists recommend:⁵
- Revised guidelines tailored to Ukraine’s realities
- Training on contraindications, not just application
- Time tracking mechanisms to mark and monitor tourniquet usage
- Promotion of alternatives, including pressure bandages and hemostatic dressings
- Trauma registries to identify patterns and inform protocol updates
Where Do We Go from Here
The rise of tourniquet-related complications in Ukraine is more than a battlefield anomaly—it’s a mirror held up to the U.S. military’s role as both pioneer and global exporter of trauma care doctrine. As the architect of Tactical Combat Casualty Care (TCCC) protocols, the U.S. armed forces are facing a moment of reckoning: when doctrine leaves the drawing board, it must evolve with the chaos it aims to tame.
In Iraq and Afghanistan, tourniquets proved lifesaving, bolstered by rapid medical evacuation and proximity to fully equipped field hospitals. But the war in Ukraine is different. Casualties are often isolated from evacuation channels, frontline medics operate with limited resources, and extended tourniquet use has led to unnecessary amputations. The “cult of the tourniquet,” born of well-intentioned dogma, risks becoming a cautionary tale.
For the U.S. military, this demands a reassessment of several key areas:
- Training Doctrine vs. Theater Reality: TCCC must be flexible enough to account for battlefield conditions, not just ideal scenarios. Over-reliance on rigid checklists can foster blind spots when evacuation is delayed or medics must improvise.
- Global Training Footprint: American trauma protocols have become the gold standard for allied forces. Without adaptive training, exported doctrine may do more harm than good in asymmetric conflicts with poor evacuation infrastructure.
- Accountability and Revision: As previously stated, Captain Rom A. Stevens, who is an original TCCC author, has publicly questioned the overuse of tourniquets in Ukraine. This rare admission signals an opportunity for honest reflection and responsibility for course correction.
- Future Battlefields: As conflict environments shift toward urban, drone-heavy, and communication-contested terrain, doctrine must anticipate trauma care scenarios that go beyond the tourniquet-first mentality. New protocols must prioritize decision-making, not just device deployment.
- Medical Diplomacy: Rewriting doctrine isn’t just an internal matter—it’s an act of global leadership. By reevaluating its trauma care standards, the U.S. can model humility and progressiveness, reinforcing credibility among its allies.
War medicine must remain dynamic, informed by experience rather than blind adherence. The U.S. military, as steward of battlefield care innovation, now faces a defining choice: cling to doctrine or embrace evolution. In doing so, it may not only improve outcomes for its own troops but offer a life-saving recalibration to those who look to it for guidance.
Footnotes
- Stevens, R. A. (2023, Interview). Ukrainian battlefield medicine under strain: Personal correspondence. ◦ The estimate of tens of thousands of amputations linked to tourniquet misuse stems from interviews with Ukrainian field medics and U.S. military doctors. While not yet supported by peer-reviewed studies, this figure reflects growing concern among trauma care specialists.
- Butler, F. K., Holcomb, J. B., & Giebner, S. D. (2018). Tactical combat casualty care 2018 update: Impact of evolving battlefield conditions on tourniquet protocols. Military Medicine, 183(3–4), e143–e149.
- Kragh, J. F., Littrel, J. M., Jones, J. A., et al. (2009). Battle casualty tourniquet use: Lessons from Iraq and Afghanistan. Journal of Trauma Injury, Infection, and Critical Care, 67(2), 336–342.
- American College of Surgeons. (2023). Stop the Bleed® campaign. https://www.stopthebleed.org ◦ STOP THE BLEED® is a national initiative emphasizing rapid bleeding control, including proper tourniquet use, in civilian emergencies.
- Association of periOperative Registered Nurses (AORN). (2020). Guidelines for perioperative practice: Tourniquet safety. ◦ Clinical standards emphasize tourniquet time limits, pressure monitoring, and early conversion to alternative bleeding control methods to avoid ischemic injury.
Disclaimer
This content is provided for informational purposes only and does not constitute medical advice.