"The price of a tourniquet is a soldier's life." Why "killer tourniquets" get to the front line and what to do about it

Recently, social media once again were shaken by hot debates over the low-quality tourniquets in the first aid kits of soldiers on the front line. This issue is not new – it has been dragging on since 2014. However, with the outbreak of a full-scale war, the military's need for tourniquets has increased, and problems with their quality have only worsened.

hromadske found out why, in the second year of the full-scale war, low-quality tourniquets are still being found in defenders' first aid kits, who is responsible for this, and what the government is doing to change the situation.

A fighter with four limbs injured who might not have made it to Medevac

A fighter named Zhoryk was covered up with soil in a dugout during the shelling. When it started, he was sleeping in a sleeping bag and did not have time to jump out along with everyone else. After the shelling, his comrades pulled him out from under the rubble. He was alive but extremely injured.

Zhoryk had fractures in both feet, a shrapnel wound to his right arm, an open fracture of his left shoulder, his face was cut by small pieces of shrapnel – one of the fragments stuck in the middle of his forehead. Tourniquets were applied to his legs and right arm.

"As soon as I saw the fighter's wounds, I became numb for a few seconds. The soldier had all four limbs injured, and I have never seen anything like this in my practice," a paramedic with the call sign Tykva (eng. Pumpkin, ed.) told hromadske.

Now, he is serving in the Pyrohov First Volunteer Mobile Hospital. His crew has been in the Avdiivka direction for a month. That is where we met Zhoryk.

"After I pulled myself together, I started to act according to the algorithm: I assessed whether the tourniquets were applied well first on his lower limbs, then on his right arm. I saw that the tourniquets were of high quality and applied correctly. Then I started cutting the clothes off his left arm and saw an open fracture of the shoulder joint," says Tykva.

Now Zhoryk is undergoing rehabilitation; nothing threatens his life and health. However, everything could have been different.

"If a low-quality tourniquet was applied on the fighter, there would be two options. Either he is taken from his position to the Medevac very quickly, and I have a better chance to apply high-quality tourniquets instead. Or, if it takes long to transport him, he would most likely not make it to Medevac alive," explains Tykva.

"75% of tourniquets are of poor quality"

Tykva is a tactical medicine instructor in the TacMed Kharkiv project. He has been working with tourniquets for over eight years since becoming a combat medic. He says that back then, they mainly used Ukrainian Sich tourniquets both during drills and on the front line. The paramedic says that Sich was the only high-quality Ukrainian manufacturer of tourniquets both in 2016 and now.

During the full-scale war, the Ukrainian army's need for tourniquets and everything else increased many times over. So, combat medics started using tourniquets from different manufacturers. The International Committee of Tactical Medicine recommends some of them. However, more and more often, fakes or simply low-quality products end up in the military's first aid kits.

How do these tourniquets still get to the front line? According to the paramedic, there are two reasons: in half of the cases, they were "handed over by the command," and in other cases, they were delivered by volunteers.

"This is quite a dangerous situation because it is ineffective. Low-quality, fake, and homemade tourniquets do not work at all – they do not stop bleeding. These are killer tourniquets," the paramedic emphasizes.

He often visits other brigades and sees what is in the soldiers' first aid kits.

"In the brigades where the unit's medic knows tactical medicine, the first aid kits are equipped with high-quality tourniquets," says Tykva.

However, in his practice, he sees such tourniquets only in a quarter of cases. The remaining 75% are fakes. They are so frequent in Kharkiv, where Tykva teaches tactical medicine classes, that paramedics have put together a collection of low-quality, fake, and homemade tourniquets, creating a kind of "Museum of Killer Tourniquets."

According to the expert, the indicators distinguishing a high-quality tourniquet from a fake one are the tourniquet model and the corresponding markings.

"For example, the CAT-7 tourniquet is properly labeled and has original packaging. It is an indication that you are looking at an original CAT tourniquet. Counterfeit tourniquets have no markings indicating their origin or are labeled differently than the original ones. And then there is Linares manufacturer, which continues to cooperate with Russia, by the way. Tourniquets manufactured by it are labeled by their company. But these tourniquets are extremely inefficient and of poor quality. That is, when you pick up a tourniquet, you can tell by the packaging or labeling whether it is of high quality or not," the paramedic explains.

"We say 'the tourniquet is bad,' they say 'prove it'"

In Ukraine, manufacturers can test their tourniquets at the Tourniquet Testing Center. This is an independent laboratory founded by volunteers to find and recommend high-quality hemostatic products for the front line.

The head of the organization, Volodymyr Yaremenko, used to manufacture tourniquets but could not scale up production. He founded the Tourniquet Testing Center (TTC) at the beginning of the full-scale invasion. Since everything was coming to the embattled Ukraine then, he had to figure out which tourniquets were good and which were not.

Volodymyr explains that there are currently no methodologies in the world that would identify a good or bad tourniquet. There is only a list of tourniquet types recommended by the U.S. Tactical Combat Casualty Care guideline.

"It is quite specific and has many restrictions. It can only include tourniquets that the U.S. Department of Defense can purchase if necessary," says the expert. "For example, the tourniquet made by the Ukrainian manufacturer Sich is not on the list, even though it has been working for us for a long time and has proven itself well."

According to Volodymyr, at the beginning of the TTC's operation, they had to conduct hundreds of studies and craft the methodology they started implementing in 2014. It implies many studies of the tourniquets' operation in critical situations: its endurance (whether it will break), the evenness of tightening during twisting, and how it will work on people with different body structures and on bare skin. And what will happen to it after, for example, two hours and at temperatures of -40 and +40 degrees Celsius. A tourniquet is recognized as high-quality when it works correctly under any conditions.

Of the more than 160 tourniquets available in Ukraine (including homemade, counterfeit, and tourniquets of dubious quality), the TTC recommends less than ten types. Among Ukrainian manufacturers, there are only two: Dnipro and Sich.

Yaremenko is convinced that the Ukrainian army's need for high-quality tourniquets will only grow.

"The thing is that a tourniquet is a single-use item. It cannot be re-applied. In combat, it is used frequently. Soldiers don't have time to think about their injuries and whether they need a tourniquet; they apply it as soon as they are injured. It means that a fighter needs a new high-quality tourniquet for each following battle. The price of a tourniquet is a soldier's life. That's why we need only the highest quality tourniquets. The ones that work and really save lives," the expert explains.

In his opinion, the problem can be solved by making independent testing of tourniquets mandatory for manufacturers.

"Right now, if we say 'the tourniquet is bad,' we hear 'prove it' in response. And there is nothing we can do about it in the legal field," says Yaremenko.

According to the expert, there is no mandatory certification for tourniquets in Ukraine.

"Sometimes manufacturers submit their own criteria for their products to certification centers. And they check whether the tourniquet meets the manufacturer's guarantees but not the effectiveness of the tourniquet in practice under any conditions," explains Volodymyr.

How Ukraine's Medical Forces Command and the Ministry of Defense respond to the problem

The Commander of the Medical Forces of the Ukrainian Armed Forces, Tetiana Ostashchenko, says that a tourniquet testing methodology and criteria for meeting the medical and technical requirements for personal protective equipment will be developed for the Armed Forces of Ukraine. According to her, tourniquets are classified as a Class I medical device and have no standard in any country in the world.

"The Tactical Combat Casualty Care Committee has an approved list of tourniquet manufacturers. But this is not a standard - these are the technical conditions of this committee. And suppose we simply transfer these manufacturers to our country. In that case, there may be accusations of corruption, as if other manufacturers are deliberately not allowed to enter the market," explained Major General Tetiana Ostashchenko.

She also noted that NATO standards are designed for expeditionary operations, not large-scale combat operations.

"That is why NATO countries, even during the meetings of the heads of medical services, listen very carefully to the experience gained by Ukrainian servicemen and revise and update their standards," she said.

When detecting low-quality tourniquets or other equipment, the service members should address the relevant request to the management.

"When there is a request to meet a certain need, it is sent to the authorized management body. The latter processes the request and sends the necessary equipment to the unit. It's the same with ineffective means. If the brigade's chief medical officer says that he has found defects [in the operation of a device - ed.], he writes a report, and the device is replaced," explains Yevhenia Slivko, Strategic Communications Advisor to the Command of the Medical Forces of the Armed Forces of Ukraine.

She adds that the army has its own architecture, clearly defined in official documents, "even if we, civilians, don't like it." 

When asked whether changes in legislation are needed to prevent low-quality tourniquets from reaching the front line, the advisor said, "There is room for improvement."

"However, the Medical Forces Command is not authorized to implement state policy, nor is it engaged in procurement. It simply has no right to do so. Therefore, accusations such as "the Command has purchased" are misinformation," explains Slivko.

We asked the Public Relations Department of the Armed Forces of Ukraine who is in charge of public procurement of medical equipment for the military. In response, we were directed to the Medical Forces Command and the Defense Ministry.

In a comment, Defense Ministry spokesman Kostiantyn Zhura told us that the Medical Forces Command is dealing with this issue.

However, in 2023, the Medical Forces Command did not purchase a single tactical first aid kit for the Armed Forces, said Solomiia Bobrovska, a member of the Verkhovna Rada Committee on National Security and a member of Holos political party. According to her, all the first aid kits are delivered to the Medical Forces Command via the International Technical Assistance, "so they are not checked and given to the troops as they are."

"It seems that a separate command creates more problems than opportunities to respond to urgent challenges at the front line and solve them. Everyone around is to blame. But not the Medical Forces Command," she summarized.

At the same time, the Commander of the Medical Forces of the Armed Forces of Ukraine, Tetiana Ostashchenko, claimed that the information about the lack of procurement of first aid kits is untrue. She explained that the data on the volume of both procurement and logistical assistance is information that is available for internal use only.

"The sources of personal protective equipment are different, so sometimes the question arises about determining the quality of what is delivered. That is why we have initiated the development of unified approaches and standards for quality assessment," Ostashchenko said.

Author: Lesia Pyniak