Choosing a tourniquet: Why are we still doing it wrong?

Ukrainian fighters are still being supplied with low-quality tourniquets that do not stop critical bleeding and, therefore, do not give a soldier on the battlefield a chance to survive. Furthermore, Ukraine has no quality standards for hemostatic tourniquets, meaning there's no way to block out the bad ones. There's no law against making and supplying inferior tourniquets to the military. Worse yet, sometimes, these subpar products are even provided to the troops by the government.

Rubryka has already discussed why top experts in tactical medicine advise using only a couple of specific tourniquets – the ones approved by the American TCCC Committee plus two from Ukrainian companies. They're really strict about steering clear of Chinese products along with all the other tourniquets from Ukraine.

Just a reminder: TCCC (Tactical Combat Casualty Care) is a US Department of Defense department that focuses on creating pre-hospital first aid protocols (US Department of Defense's Committee on Tactical Combat Casualty Care).

The possessions of the injured people who were evacuated during the two-hour battle. Photo provided by Borys Khmilevsky

"One of my soldiers died because a substandard tourniquet was used on him," said Alina Sarnatska, a sergeant of Ukraine's armed forces and company combat medic.

"I also ran into uncertified tourniquets during my work at the front, which were ineffective and did not stop the bleeding. Fortunately, in my experience, people survived because they had time to be transferred to an evacuation center where there were normal tourniquets," says Borys Khmilevsky, a combat medic, tactical medicine instructor, and head of the Paralegal Hub.

"This is the situation: you've got a wounded man in front of you, bleeding, and he has got two Chinese tourniquets on the same limb, but they are not working. You replace them with a quality one, and it starts doing its thing," says the director of the communal enterprise "Hospitaliers of Dnipro" and head of the training center "Hospitaliers" Oleksandr Syvyryn.

Regrettably, countless stories and social media posts exist regarding cheaply made products with exceedingly short straps that are not suitable for use on people's legs.

"Unfortunately, I know that many guys also believe that "if the word 'tourniquet' is written, it means a tourniquet." And I saw with my own eyes how these tourniquets fly apart when soldiers try to tighten them on the limbs. And how the guys are bleeding.

Have you seen what people who have lost all their blood look like? Their skin is pale and gray, like parchment, and they are wearing blood-black clothes under the tourniquet, which is "better than nothing." I've got some pretty rough pictures on my phone – definitely not suitable for posting on Facebook," a soldier and volunteer Lesia Lytvynova (Oleksandra Koval) noted recently in her post.

"This is a problem with two components. The first is that sub-par products are being imported into Ukraine. The second is that the manufacturers started producing shoddy goods," says Oleksandr Syvyryn about the situation with low-quality tourniquets. "When they looked at it [a tourniquet – ed.], they thought, "It can't be that hard; it's just a loop, some buckles, and some Velcro. We already have machines that can sew underwear – why don't we start using them to make tourniquets?"

Manufacturers that think this way don't consider that the tourniquet is actually an advanced tech product that has been tested in the US for years. Therefore, the military instructors accumulate whole collections of low-quality tourniquets, which they take from the fighters.

Experts note that if any of the technical requirements for tourniquet elements aren't met, it can make the tourniquet either wholly ineffective or much less effective than usual.

"This isn't something you'd want to test to see if it works because there may not be a second chance. When a person sustains an injury that causes them to bleed critically, they can pass out in significantly less than one minute. You apply a tourniquet, and if, in the process of application, it turns out that it does not work, there is a huge risk that your life will end there. Because with critical bleeding, a person dies in three minutes," says Borys Khmilevsky.

Oleksandr Syvyryn lists the arguments of manufacturers and suppliers of low-quality products:

• "We have already delivered 100,000 units to the army, and no one complained";

Oleksandr Syvyryn's counterargument: "The dead do not complain."

• "The doctors we know took a look and said that this is totally normal";

Without an approved testing methodology, an adequate specialist cannot guarantee the quality of the tourniquet simply by twisting it in his hands; experts are convinced.

"Of course, it's a shame that, after all these years of war, the state still hasn't figured out what constitutes a high-quality tourniquet and what a low-quality one," says the co-founder of the Leleka Foundation, Yuriy Kubrushko.

In his opinion, one of the reasons for the disappointing situation is the lack of a common position and common enlightenment both on the part of the state and on the part of the volunteer-instructor-medical community.

So the first problem is that there are no evaluation methods, criteria, designated laboratories that can do certain research, and no state-recommended lists of hemostatic tourniquets.

The second problem is that in the absence of any objective information, the issue of purchasing a tourniquet is decided according to the principle of who believes whom and who believes what, says Yuriy Kubrushko:

"Then we have a situation when someone trying to use a tourniquet didn't work, and everybody started thinking the item was bad. But when another person tried it and succeeded, everyone changed their minds and thought it was cool. Then the Facebook battle begins: whichever tourniquet receives more reviews and favorable comments is considered good. It shouldn't be like that."

Unfortunately, the problem of low-quality tourniquets was not recognized officially until recently. At the end of July, a group of more than 40 representatives of volunteer movements, combat medical instructors, and public organizations released an open letter to the Ukrainian Ministry of Defense, the Ministry of Internal Affairs, the Commander-in-Chief, and Chief of the General Staff of the Armed Forces, urging them to take immediate action to reduce the number of military personnel who die before they can reach stabilization camps to receive doctors' assistance.

Tourniquets are the first of the eight biggest problems that the authors of the appeal called out in tactical medicine.

This is how it is articulated in the appeal:

"1. There is no quality control of medical devices (tourniquets, occlusive stickers, etc.), which the state transfers to military units. In particular, no requirements approved by the Ministry of Defense for the means of tactical medicine directly affect the life of a serviceman – namely, hemostatic tourniquets.

The state receives part of the means as humanitarian aid from philanthropists and other countries; part is purchased from the state budget. At the same time, all of them are transferred to combat units without proper quality control and without following the recommendations of the TCCC (Tactical Combat Casualty Care) Committee, created under the US Department of Defense. This organization is the world's most authoritative source in the field of tactical medicine and the developer of relevant standards."

Viktor Appolonov, a co-founder of the Tourniquet Testing Center and one of the signatories of the petition, has noted that the Command of the Medical Forces of Ukraine's armed forces doesn't have a system in place to monitor and evaluate hemostatic agents that are either donated by people or bought by the government. He believes that this results from the "Soviet" style of governing people's lives:

"The cost of training a soldier of certain military branches has been calculated in the United States. And, of course, if his preparation costs 25-50 thousand dollars, then he will, among other things, buy the relevant tourniquet. For the army, the manufacturer of tourniquets has very significant discounts. In our country, no one considers this. And, unfortunately, in general, politics is still such that the life of a soldier is not valued."

Liubov Halan, co-founder of the "Pryntsyp" [Principle in Ukrainian – ed.] human rights center, emphasizes the significance of the human factor when it comes to providing the military with adequate means:

"There's a huge difference between what's written down and the actual needs. In fact, the provision of the unit depends on the extent to which the people who serve have the responsibility and motivation to ask for something, complain about something, check something, engage in personnel training, etc."

"At the brigade and medical service levels, we need to know what supplies we can use and which we shouldn't. The troops should know this too, but they don't always have the competence and understanding," says Liubov Halan. "Whenever I watch news or photos from the front lines, I always take notice of the tourniquets attached to people's body armor. It's really eye-opening to see just how much subpar gear our troops have to use, and it could come from various sources."

Unfortunately, there is no legal obligation for supplying, making, or using low-quality tourniquets, as Rubryka already wrote.

"As there are no quality standards for tourniquets, you can take anything, say it's a tourniquet, and from the point of view of our regulations, it will be a tourniquet. Because it is not written anywhere what it looks like and what characteristics it should meet," says Borys Khmilevsky.

Liubov Halan and Yuriy Kubrushko, the ones who signed the appeal, told Rubryka that everyone responded to it except for representatives of the main departments – the Ministry of Defense and the National Guard of Ukraine.

According to Liubov Halan, the Ministry of Health took responsibility for setting the minimum quality standard of tourniquets. Rubryka also sent a request to the ministry to gather more information but didn't get a reply back before the article was published.

A working group should be created to develop testing methods and develop a single standard for evaluating personal protective equipment.

"We expect a more systematic solution in all logistics, which concerns the issue of material and technical support," says Liubov Halan. Thus, the decision about which means will go to the army should be made even before they cross the border of Ukraine.

Also, the chiefs of the medical department in the army were obliged to conduct an inventory of the available means, but experts were quite skeptical about this. After all, how will military medics evaluate the suitability of tourniquets if they have no criteria by which to assess them?

The state might come up with the idea of adding a tactical medicine advisor at each brigade, but without knowing what the role would have in terms of responsibility, volunteers and instructors wouldn't be able to give an opinion about it.

According to the co-founder of the "Pryntsyp" NGO, the reputation institute works quite effectively in the volunteer community.

"If any of the volunteers discover that other volunteers are distributing unreliable materials, they'll be made aware that they are of poor quality. They will then need to be mindful of what they're providing and explain why they're transferring it. The tactical medicine foundations that I know show every day in pictures exactly what they convey, what it looks like. There is an institution of reputation, and people feel responsible," Liubov Halan believes.

She also talks about her own volunteer initiative that's not connected to "Pryntsyp":

"When we receive medical supplies from some colleagues from abroad, we check everything. It also happened that half had to be thrown away because it would not suit the soldiers."

Rubryka also wrote about the Tourniquet Testing Center. Initially, it was created under the auspices of the Ministry of Health, and then representatives of the center formalized their volunteer initiative as a public organization. The initiative was launched on February 24, 2022, to screen out not only low-grade imported goods but also the "creations" of domestic "inventors" of all sorts based on scientific evaluation, according to Viktor Appolonov, the representative of the Center.

 Volunteer Yuriy Kubrushko suggests that ramping up the Tourniquet Testing Center might be an answer to the tourniquet dilemma:

"The specialists of this center are perhaps the best in Ukraine in understanding the properties of turnstiles, their modes of operation, and how to properly test them. Their research results, in principle, confirm the American TCCC standards, which is also an indicator of adequacy and reliability of information for us."

Unfortunately, because this center is a public initiative, official bodies can't use their recommendations and conclusions to make buying decisions, partake in it, or even ask volunteers or foreign partners to contribute.

Yuriy Kubrushko believes that if the Tourniquet Testing Center were legalized in the state and had the equipment and official regulations in place, it would be an enormous step forward.

According to Borys Khmilevsky, a combat medic and tactical medicine instructor, today, Ukraine is unlikely to be able to develop a national quality standard for tourniquets:

"To develop it, you have to have access to production — you have to control it because you have to be sure that the next batch is as good as the last. It takes much time to study how a tourniquet works in the laboratory, and it takes much time to study how it works in the field. And it takes much time to study how this tourniquet affects the recovery of fighters. We don't do any of this and can't do it now."

As a compromise solution, Borys Khmilevsky proposes adopting the TCCC Committee's recommendations at the state level.

"This is not the best thing that can be done because they [ TCCC standards – ed.] do not take into account the interests of national producers, but it is better than nothing," says Borys.

Viktor Appolonov, representative of the Tourniquet Testing Center, says that standardizing tourniquets needs a lot of scientific work, which, unfortunately, no one has conducted in the Command of the Medical Forces.

If there's a genuine wish to sort out the problem of poor-grade tourniquets, Viktor Appolonov prescribes getting in contact with "Dnipro," the Ukrainian producer of tourniquets, with a laboratory included.

"This tourniquet is made based on significant engineering studies, practical studies, there is a certain technique," says Viktor Appolonov.

Generally, the expert doesn't see an immediate fix for the issue either. According to him, the most efficient resolution would be to adopt the TCCC Committee's list and implement it with the Command of the Medical Forces via an order. Then, foreign contributors are requested to procure items from said list.

Unfortunately, as long as the state keeps making its decisions, the war will continue, and the need for tourniquets won't get any less. So, how to choose a tourniquet for yourself, your family, or your comrades in the army?

Viktor Appolonov cautions: the tourniquet is not something you can just buy at a store based on what's written on it; it is a specialized item.

Experts Rubryka talked to suggest picking products only from the TCCC Committee's list.

It should be noted that 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.

For its part, the Tourniquet Testing Center NGO checked a certain number of tourniquets from the above list.

"The problem is that TCCC's recommendations and tools are tailored to their realities. In the USA, the "golden hour" rule applies when a wounded person is transported from the place of injury to the hospital within an hour at most. And with us, it can take from 20 minutes to 12 hours. That's why their toolkit doesn't work the way I personally would like," says Viktor Appolonov, a representative of the Tourniquet Testing Center.

Tourniquet Testing Center suggests using CAT, SOFTT-W, TMT, and SAM XT tourniquets and products from two Ukrainian producers: "Dnipro" and "Sich." The lists from TCCC and Tourniquet Testing Center match and don't contradict each other.

Oleksandr Syvyryn, director of "Hospitaliers" of Dnipro and head of the training center of "Hospitaliers of Dnipro," emphasizes that to use the tourniquets, you need to understand how to operate them. 

"If you have a group of people trained on how to use CAT tourniquets but then give them SAM XTs, which are also good but with different overlays, then when people need to use them urgently, it might not end well," warns Oleksandr Syvyryn.

People will have already developed somewhat different skills.

In his opinion, the lack of uniformity in available tourniquets is detrimental to the uniformity of training provided.

He also uses the Ukrainian harness "Sich" as an example, which has been proven reliable over time:

"This tourniquet is pretty good and of high quality since we got it ourselves and use it; however, it has its differences. Replacing it with a CAT tourniquet would be a bad idea because you need time to work out all the overlay details."

"The tourniquet that you know how to use is suitable for you," says Oleksandr Syvyryn.

So the first thing should be the training itself, during which you will twist these tourniquets in your hands, be shown how to use them, and be given the opportunity to try them on yourself.

Oleksandr Syvyryn is convinced that this can't be learned from video instructions – it needs to be practiced to get the hang of it, which is why the most helpful tourniquets are the ones you remember how to use.

The director of "Hospitaliers of Dnipro" said no worthwhile courses can be taught quickly:

"If they're saying they'll teach you how to stop bleeding, perform resuscitation, and fight with swords all in one hour, they're trying to deceive you. That's impossible; a decent trauma care course usually takes eight hours."

When choosing, pay attention to the price, too. Without a sponsor, the typical course shouldn't cost a hundred hryvnias since the instructor's labor and the use of training facilities must be compensated.

Once more, the cost. A standard CAT typically costs 1,500-1,800 UAH per unit, and quality tourniquets made by Ukrainian manufacturers cost no less than 500 UAH.

Unfortunately, many knockoffs are out there nowadays, and they're made well. They are ineffective, but it isn't easy to distinguish them from the original without being a specialist. So, it's best to only buy from trusted stores.

The tourniquet must have the original instructions for use, plus the name, manufacture date, batch number, and serial number imprinted on it.