The uses and dangers of tourniquets in combat medicine

In the modern battlespaces of Ukraine, where artillery shrapnel, drone-delivered munitions, and anti-personnel mines are a daily hazard, the tourniquet has re-emerged as one of the most essential—and controversial—tools in frontline trauma care. Once dismissed as a last resort of questionable value, the tourniquet has been rehabilitated in military doctrine, particularly since the wars in Iraq and Afghanistan.

In Ukraine, where medical evacuation times are highly variable and combat medics must make life-saving decisions under extreme duress, tourniquets are deployed widely and often. Yet despite their life-preserving potential, tourniquets are not without their hazards. Their misuse can lead to permanent disability or even death. We examine the critical role of tourniquets in Ukraine's war medicine, explore their dangers, and consider viable alternatives within the constraints of wartime field conditions.

The Return of the Tourniquet: A Tool for Modern War

Tourniquets—tight bands designed to constrict blood flow to a limb—have existed for centuries, but their application in combat medicine declined during the twentieth century amid concerns about complications such as gangrene and limb loss. However evidence-based research from NATO operations in Iraq and Afghanistan has vindicated their proper use. Battlefield studies demonstrated that rapid application of a tourniquet could drastically reduce preventable deaths from exsanguination ("bleeding out"), particularly from injuries to extremities.

In Ukraine, the decentralised, drone-saturated nature of warfare—with mobile, small-unit actions across vast territories—has revived the necessity of tourniquets. Ukrainian medics and soldiers are trained to self-apply Combat Application Tourniquets (CAT) or windlass-based systems within moments of traumatic injury. This is often done even before a medic arrives, especially in cases where arterial bleeding is apparent. Commercial-off-the-shelf (COTS) solutions have proliferated in Ukraine, with Western-supplied equipment supplemented by domestic and improvised alternatives.

The effectiveness of the tourniquet lies in its ability to control catastrophic haemorrhage—the leading cause of preventable death in combat. Ukrainian studies and field reports suggest that the survival rate for those reaching stabilised medical care after rapid tourniquet application is high, particularly among those wounded in lower extremities by landmines or drone strikes.

Dangers and Complications: When a Life-Saving Tool Becomes a Liability

Despite their proven utility, tourniquets carry significant risks. If applied incorrectly or for too long, they can cause irreversible tissue damage, nerve compression, or even precipitate limb amputation. This is especially pertinent in Ukraine, where evacuation delays—caused by Russian artillery interdiction, drone surveillance, or winter road conditions—can prolong field care beyond recommended safe durations. The "golden hour" of trauma medicine is often a luxury in Donbas or Zaporizhzhia.

There are documented cases of Ukrainian soldiers reaching field hospitals with tourniquets still in place three to six hours after application—well beyond the recommended maximum limit of two hours. This can result in ischemic necrosis of muscle tissue, increasing the likelihood of amputation. Moreover untrained application, particularly with non-standard devices such as belts, wires, or plastic ties, can exacerbate injuries. Makeshift tourniquets, though born of necessity, may not generate sufficient pressure to occlude arterial flow and can give a false sense of security.

Another danger arises from what medics call "tourniquet complacency"—a tendency to apply them routinely even when direct pressure or haemostatic (blood clotting) agents might suffice. Over-reliance on tourniquets can crowd out critical thinking and triage discipline, especially amongst poorly trained personnel or in the chaos of mass casualty events.

Alternatives and Complementary Measures

Recognising the limitations of tourniquets, Ukrainian combat medicine has increasingly embraced a multi-modal approach to haemorrhage control. Alternatives such as haemostatic dressings—impregnated with agents like kaolin or chitosan—offer effective bleeding control, particularly in junctional areas where tourniquets are ineffective (e.g. groin, armpits, neck).

Pressure bandages such as the Israeli bandage, or newer innovations like the Emergency Trauma Dressing (ETD), provide adjustable compression and are often sufficient for venous or moderate arterial bleeding. For pelvic injuries, which are not amenable to standard tourniquet use, pelvic binders and junctional tourniquets (such as the SAM Junctional Tourniquet) have been introduced in some Ukrainian field hospitals, though their distribution remains limited.

In addition, Ukrainian medics are being trained in Tactical Combat Casualty Care (TCCC) protocols, where tourniquet use is only the first step in a broader algorithm. Once the casualty is in a safer location, medics may conduct a "tourniquet reassessment drill" (TRD), loosening the device to see if bleeding can be controlled by other means. This reduces the risk of unnecessary ischaemia (tissue damage due to lack of blood flow).

Moreover innovations such as REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta)—a minimally invasive procedure to stem torso haemorrhage—are being explored in rear-echelon medical facilities, although these remain rare and require specialist training. REBOA involves the insertion of a catheter with a balloon into the aorta, to stop blood flow to the lower body, so is not undertaken lightly. Training of combat medics in Ukraine is often minimal, so skills such as learning how to use a REBOA are rare.

The Moral Dilemma: Saving the Soldier, Losing the Limb

The harsh arithmetic of battlefield medicine often requires choosing between life and limb. Ukrainian doctors are acutely aware that a soldier with a prosthetic leg may return to civilian life or even rejoin combat, but a dead soldier cannot. This logic underpins the emphasis on tourniquet training and rapid application.

Yet such utilitarian calculations do not diminish the moral and psychological costs of avoidable amputations, particularly among young soldiers who survive only to live with lifelong disabilities. Ukraine has seen a surge in demand for advanced prosthetics, rehabilitation programmes, and psychological support for amputees.

In the broader context of Ukrainian resilience, every saved life matters—but so does the quality of life. Combat medicine in Ukraine must therefore navigate a difficult path between urgency and caution, innovation and improvisation, doctrine and reality.

Tools, Not Crutches

Tourniquets in wartime Ukraine symbolise both the brutal necessities of war and the hard-earned lessons of modern trauma medicine. They are not panaceas, nor are they relics of a bygone era. When used correctly, they save lives. When misapplied, they can ruin them.

As Ukraine’s battlefield medicine continues to evolve, the challenge lies not in abandoning the tourniquet, but in integrating it into a sophisticated, context-aware trauma response system. This means more training, better equipment, faster evacuations, and above all, a clear understanding that even the simplest tools require disciplined minds and humane judgment.

In the fog of war, the tourniquet is both weapon and wound, guardian and gamble—a tight band drawn not just across a limb, but across the fine line between death and survival.