Better nothing than a tourniquet that will kill: how to protect fighters from low-quality tourniquets

Providing military personnel at the front with blood-stopping tourniquets is complex. Among those received by fighters, a large proportion are Chinese-made, which experts do not advise using. Rubryka found out why this happens and how to change the situation.

"Don't buy 'it's better than nothing,' because in this case, nothing is better than, for example, a killer tourniquet," stated the post distributed by the General Staff of the Armed Forces of Ukraine on June 10, 2022.

After the period of 2014-2015, when the war was raging in the east of Ukraine, it was in the first months of the full-scale war that this problem became particularly acute.

This problem was so acute at the beginning of Russia's large-scale invasion of Ukraine that Ukrainian fighters had to use cut tires from bicycles, and it was better than what was given to the soldiers under the guise of tourniquets. In 2022, no one could get normal quality tourniquets because the manufacturers were simply not ready to meet such a huge demand.

For example, Ukrainian manufacturers of the SICH tourniquet were affected by hostilities and could not quickly resume production. Now, little by little, the situation is improving, says Oleksandr Sterlikov, senior instructor of the Freelance Center for Tactical Medicine.

However, the provision of military tourniquets and the quality of the many tourniquets the soldiers have are still far from satisfactory.

"There is a shortage of tourniquets, especially high-quality ones, but it cannot be said that the state does not provide them — it does. The state buys Ukrainian-manufactured tourniquet SICH, and original CATs, so do various funds. Does it happen that low-quality tourniquets come from the state? Yes, this also happens. These are not the most common cases, but they do happen," says Volodymyr Prytula, a volunteer and TCCC tactical medicine instructor at the ASM level.

Rubryka spoke to four experts, who are all categorically against the use of devices that Ukrainian engineer-entrepreneurs tried and are trying to make on their own to satisfy the need for hemostatic tourniquets.

"They know how the tourniquets work but don't understand what they should be like," Sterlikov formulates the problem.

Victor Appolonov, a representative of the Tourniquet Testing Center, emphasizes: the tourniquet seems to be a simple device only at first glance. It is high-tech and contains many nuances that have undergone a long evolution. Those who try to make DIY tools do not know or consider these nuances.

What function should a quality tourniquet perform?

On the battlefield, the priority is self-help, because the tourniquet is a means of combating massive blood loss right on the battlefield.

"They say that the best help on the battlefield is to fire in the direction of the enemy. This is how we nail the enemy to the ground, and at this time, the wounded person can try to help themself," explains Appolonov. The hemostatic tourniquet should be designed considering the injured person's physical and psychological state. The fighter is already on the battlefield under constant stress, and physical injuries only add up.

Damage to the main vessels of the upper and lower extremities and the massive bleeding that occurs quickly lead a person to a state of helplessness. In the worst case scenario, if a person is conscious but has damage to, for example, the femoral artery, they have 30 seconds, no more than 40, to help themself.

Therefore, a high-quality tourniquet combines engineering solutions calculated to the smallest detail. For example, in the tourniquets of the collar type, which are the majority in Ukraine, the length of the tape, the material, and the protrusion under the collar are adjusted. They provide the necessary range of operation of the tourniquet: in a maximum of four half-turns, fixation can be achieved on the most complex areas. The expert explains that according to the Tourniquet Testing Center, the most difficult area is the lower limb, with a circumference of 70+ centimeters and a substantial fat layer.

How does the technology work? The under-turning piece of the inner sling should allow the injured person to easily start twisting the windlass because the person quickly loses strength. And if they can start, it will be easier to perform the necessary rotations. If the tourniquet is tight and does not allow to start the fixing easily, this may mean the death of the fighter. In the same way, if the tourniquet does not hold the overlap for two hours without leaking blood, a person may die on the way to the hospital.

There are normal tourniquets in Ukraine and all sorts of unnecessary junk, Appolonov says, because large batches of such tourniquets came in. 

Such products are cheaper, and sometimes volunteers, unfortunately, still buy them for the soldiers because you can buy more of them for the same amount of money.

Unfortunately, there were many deaths from such tourniquets in the Ukrainian army, experts claim.

"The other day, I saw two tourniquets for sale at the military store. One is high-quality, expensive, and the other is made-in-China for $12," Sterlikov shares. "I know real cases when people died because of poor-quality tourniquets. Especially at the beginning of a full-scale invasion, there were a lot of such tools, which seemed to work at first, and then the person simply could not be delivered to the hospital because the tourniquet fell apart."

Appolonov says that most made-in-China products do not differ from each other. They all look the same. They are black with a red tip, and no information about the manufacturer. At most, there can be some name in Chinese.

Just because this product won't break when applied doesn't mean it will workChinese models mostly break at the application stage, but if it is strong and has not cracked, this does not mean it is of high quality. On such samples, where the inner sling is thick enough not to tear under any pressure, a peculiar phenomenon can be observed — a disproportionate increase in pressure for each half-turn of the rod.

The main thing that such a phenomenon leads to is the physical impossibility of creating the necessary level of pressure not only for an injured person but also for a completely healthy one. Also, the poor elasticity of the strap leads to such tourniquet working only once in a while. There are two opposites among Chinese models: they are either thick or thin. This is in addition to other disadvantages.

"If you give a person a made-in-China tourniquet, they have hope for salvation. This person does not bother and does not look for another harness," Yaroslav Vus, the head of the All-Ukrainian Union of Paramedics, outlines the sad but very real picture. "If this person gets injured and uses this made-in-China tourniquet, and it breaks, the person dies." If they were not provided with this tool, they would have looked for a high-quality one. 

The situation is further complicated because unscrupulous manufacturers have begun to make fakes for original certified tourniquets.

"Now, made-in-China fakes are almost impossible to distinguish from the original — they have all the stamps and similar packaging," says Sterlikov, senior instructor of the Freelance Center for Tactical Medicine. "It is clear that although it looks similar, it does not work because it's a low-quality tourniquet."

There are also Chinese replicas on the market, for example, CAT-type tourniquets. "It's not even a fake. It just looks like a CAT tourniquet, but this tool doesn't work either," adds Prytula.

The Ukrainian army is largely people-sponsored. This is a plus because volunteers and all those who care try to cover needs for which the state lacks resources. This is also a minus in terms of approaches to providing soldiers with first-aid kit components.

For example, in the American army, everything is standardized. A fighter receives only proven tools, which he receives in no other way than from his army. Since 2014, the needs of the Ukrainian army have largely been covered by volunteers and donors. Suppose a charitable batch of made-in-China products entered Ukraine by mistake and was transferred officially to the balance of some military unit. In that case, until it is all used up, nothing else will be provided.

In the American army, for each case of use of components from an individual first-aid kit, which was issued centrally, an investigation of the case of traumatism with the appropriate registration must be carried out. Unfortunately, in this aspect, the Ukrainian army is still behind, according to Appolonov.

At the state level, there is still no full understanding of how important it is to provide tourniquets, especially high-quality ones, experts say.

The head of the All-Ukrainian Union of Paramedics, Vus, draws attention to harmful mental traits of Ukrainians: trying to save and take by quantity, not quality. In this way, those volunteers who care more about their ambitions than the real needs of the fighters earn glory by handing over a thousand low-quality tools instead of a hundred high-quality ones.

"The quality of tourniquets cannot be checked without laboratory tests. If a volunteer puts it on his leg and says: 'Oh, it's numb, I don't feel anything, it works!' — this is by no means an indicator of quality. It is necessary to obtain laboratory confirmation," says Sterlikov.

• Tourniquet Testing Center

On February 24, 2022, when Russia started war against Ukraine, the Tourniquet Testing Center was created to filter out not only low-quality foreign products of factory production but also products of Ukrainians' creativity, says a member of the Center Appolonov.

The Tourniquet Testing Center was originally created under the auspices of the Ministry of Health. At first, five people were on the team, but over time, some dropped out because this was unpaid work. Through its own efforts, the Center created a laboratory in Lviv that allows, using improved methods, to research tourniquets. In this laboratory, products are tested, and conclusions are given regarding this product's (un)suitability.

Over time, the number of members of the Center decreased, and only Appolonov and his colleague Volodymyr Yaremenko remained. They created a non-government organization to have official status. "There is no more influx of low-quality stuff, as was in the first seven months of the war, so now this number of people is enough," Appolonov says.

The expert also draws attention to the fact that it is important to control the production of tools, "It is not enough to make, for example, ten normal tourniquets. Maintaining the quality in entire batches of thousands of pieces is necessary

• Improvement of the certification process

The problem is that even low-quality tourniquets can meet the certificate of conformity because the certificate of conformity is literally a certificate that this product has a strap, a rod, and a band. Technically, this is a tourniquet, but it does not save lives, says Sterlikov. "Everything that Ukrainian woe inventors make and sell, they do within the current rules."

There is no standard for what a tourniquet is. There are no clear requirements for this product. The tourniquet still passes the Ukrainian classification of foreign economics goods codes as a textile product or as a product with a metal bottle. That's how it is certified, unfortunately," says Prytula.

Sterlikov notes that outlining quality criteria and taking it through the Ministry of Health and other authorities is a tremendous assignment.

• Prosecution

"The situation could be changed if the transfer of low-quality tourniquets were punishable as murder or treason, for example, 15 years in prison. There would be two or three such cases, and the rest would already buy what is necessary, not what is cheap," Vus is convinced.

So far, this is all purely the moral responsibility of producers, sellers, volunteers, and everyone else involved.

• Informational and educational work

On this, Sterlikov advises focusing on fighting with information, explaining to the fighters, and showing why a low-quality tourniquet can kill.

On his Facebook page, Vus regularly posts videos of various DIY machine guns and ironically assesses the characteristics of these products, which continue to be sold en masse in Ukraine.

Historically, such tourniquets were produced and such standards were developed in the US, and the whole world is guided by them.

Committee TCCC (Tactical Combat Casualty Care) is a unit of the US Department of Defense that deals with the formation of pre-hospital first aid protocols (US Department of Defense's Committee on Tactical Combat Casualty Care (CoTCCC).

It recommends certain tools for the US military, particularly for first aid. There is a list of these tools, i.e., the same tourniquets. Many years of work and millions of dollars have been invested in this. Therefore, there are high-tech and proven self-help tools at the output.

The TCCC Committee recognizes and recommends tourniquets:

• CAT (the seventh generation of this tool has already been developed)
• SOFTT-W
• SAM XT
• TMT
• RMT
• TX2 & TX3.

Volodymyr Prytula, the TCCC tactical medicine instructor at the ASM level, advises using only them.

"Not all tourniquets from the TCCC list work, and we don't know why. Our conclusions are based on the study of those samples that fell into our hands," says Appolonov, a member of the Tourniquet Testing Center.

Tourniquet Testing Center recommends using CAT, SOFTT-W, TMT, and SAM XT tourniquets.

"We passed them through our laboratory, so we recommend them for use in our army. Plus, we recommend the Ukrainian tourniquet SICH. First, it was developed with the help of the Ukrainian medical community. Secondly, it has a fairly large background of use, as already for eight years they have been used during Russia's war in Ukraine's east," says Appolonov. "During this time, we admitted one more Ukrainian manufacturer — the DNIPRO tourniquet."

All experts also agree that the tourniquet should go with the skill of using it and with the desire of the fighters to train, as Prytula noted. Much depends on the commanders who can provide such training for the fighters.

"The tourniquet is the second most important thing for a fighter after a personal weapon," Appolonov is convinced. If every soldier, volunteer, manufacturer, supplier, and state, in general, understands that — the means of rescue will genuinely be saving.