A thin pink strip of rubber”: Russia’s Failure in Combat Tourniquets in the Russo-Ukrainian War
CPT Matthew D. Turner, MD, MC USA
U.S. Army, Emergency Medicine Residency, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033
COL Jason Sapp, MD, MHPE, MC USA
U.S. Army, Transitional Year Program/Department of Medicine, Madigan Army Medical Center, 9040A Jackson Avenue, Joint Base Lewis-McChord, WA 98431
Introduction
Isolated limb exsanguination is the most common preventable cause of death on the battlefield. During the wars in Afghanistan and Iraq, the U.S. military’s adoption of the Combat Application Tourniquet (CAT) and training in tourniquet application through programs such as the Tactical Combat Casualty Care (TCCC) course dramatically lowered combat casualties, by one estimate saving 1,000-2,000 US lives from 2001 – 2009 alone. Militaries around the world have since emulated this life-saving training,1 including Russian forces.2
In early 2022, Russia began preparing for the medical requirements that a full-scale invasion of Ukraine would require, with multiple field hospitals built along the borders of Ukraine, “blood drives of university students… military medical exercise that used large anaesthetized animal models, and medical evacuation chains in place”.3 Despite these preparations, Russian forces almost immediately began to face significant shortages of medical supplies, likely due in large part to the separation of logistical and operational planning in the first stages of the war,4 over-extended lines of communication, and simple “wishful thinking”.5
Russian Medical Supply
Independent Russian newspapers report that Russian forces have consistently been “unsuccessful in establishing a reliable supply chain for both border clinics and military hospitals”.6 Even with the tacit support of Belarus is not enough; one Belarusian doctor noted that Russian casualties sent into his country for treatment emptied his city’s entire blood reserves within a mere 2 days.7 Dozens of small-scale volunteer organizations have arisen to raise funds for medical supplies as varied as hemostatic sponges,8 notebooks for handwritten medical records, disposable wipes, prescription medications such as propofol and rocuronium, and syringes.6 With a looming shortage of physicians, the government has barred large numbers of doctors from leaving the country and has put pressure on Belarusian physicians to fill the gaps.7 Even with this, “hospitals in occupied territories consistently remain overfilled and understaffed”.9 The war has had significant consequences for the civilian Russian healthcare system as well; prices for medications have surged as the Russian pharmaceutical industry, highly dependent on foreign imports, has suffered under economic sanctions.10 The country is experiencing a shortage of prosthetics and has significantly scaled back surgeries such as knee arthroplasty.10
Russian forces suffer from a significant lack of medical supplies – one video on social media “reportedly showed Russian officers telling new conscripts to purchase tampons to plug bullet wounds”.2 Many units, such as the 113th Regiment of the self-proclaimed Donetsk People’s Republic (DNR), have made public video appeals to Putin, complaining of lacking adequate medical supplies.11 When medical supplies are available, they may be lost to corruption. One Russian POW recalled in a CNN interview that his “commanders got high on the stock of painkillers they had”.12
Tourniquets
In particular, Russian forces appear to often lack the combat application tourniquet2 that is key to proper hemorrhage control in TCCC. In one video on social media, conscripts are told by an officer, “Tourniquets, I don’t have enough tourniquets for all of you… Take them out of your cars, get the tourniquets from there… You have money in any case, ask your relatives [to] buy something somewhere…”13 Many servicemen purchase their own medical kits on websites such as Avito, where a “bare minimum” kit that includes “antibiotics [and] tourniquets” can cost 20,000 rubles ($325 USD) – a high cost for an average monthly salary of approximately 200,000 rubles ($3,365 USD).14 Even when high-quality combat tourniquets are available, first-aid awareness and training is poor. In a 30 September 2022 intelligence update by the UK Ministry of Defense, the Ministry noted that some Russian troops have secured their tourniquets to their equipment with cable-ties instead of Velcro, “probably because such equipment is scarce and liable to [be] pilfered”. However, the cable-tie renders the tourniquet nearly “impossible” to quickly and effectively use in the chaos of the battlefield.15 A 2014 Military Medicine study found that tourniquet application skills significantly declined under simulated combat, even with properly-trained soldiers.16 In the poor “recruiting, equipping, and training” of the Russian military,5 the decline in tourniquet application skill is likely far worse.
Training
Even when tourniquets are used, they are often applied improperly due to poor training, or are ineffective, low-quality alternatives,6 such as a “thin pink strip of rubber”.17 The Esmarch tourniquet has been described by a Russian military paramedic as a “rubbery red [expletive] [that had been] in the talcum powder for years… are they [expletive] serious?”18 One source estimates that over 30% of Russian amputations “were performed due to improper application of tourniquets”;6 the UK Ministry of Defense has also noted that “up to 50 percent of Russian combat fatalities could have been prevented with proper first aid,” noting that the two biggest contributors were slow evacuations and inappropriate use of tourniquets.19 In many field hospitals, even the instruments for amputations are reportedly running dangerously low.6 Evacuation lines are often prolonged, resulting in wounded soldiers with “gangrenous, shattered limbs… [who had] been wearing tourniquets for days to staunch the blood”.7
It is likely that the structure of the Russian military, which operates with far fewer support soldiers than other militaries,20 has exacerbated the problem of inadequate training and medical supply. Shockingly, for the first seven months of the invasion, the Russian military did not mobilize any combat medics – up to October 2022, first aid and evacuating the wounded had to be done by other soldiers.21 Many current Russian medics are women and face severe sexual harassment and assault and pressure to become “field wives” for superior officers,22 further harming the morale and effectiveness of those valuable units.
Further compounding the toxic, abusive atmosphere of the Russian medical corps is that any criticism of the military is politically dangerous. Dr. Yuri Yevich, one of the primary forces in the field of Russian tactical medicine and a pro-war figure since the initial Donbas 2014 invasion, has been charged by Russian authorities for “discrediting the Russian armed forces” following an April 2023 lecture where he critiqued the current state of Russian combat medicine.23 In such an environment, it is doubtful that Russia’s forces will significantly improve their tourniquet supply, training in combat medicine, or application of tourniquets in the foreseeable future.
CASEVAC
For years, Russian army publications called for the “golden hour”24 – the initial 60 minutes following a traumatic injury – to guide immediate casualty evacuation. However, in the grinding battlefields of Ukraine, immediate CASEVAC has been nearly impossible, particularly with the intensive “casualty-heavy approach to fighting” of the Russian military, which often results in the need for mass casualty evacuations.24 Russian medical evacuations are often severely delayed and result in prolonged tourniquet times. This delay has resulted in thousands of unnecessary amputations among Russian casualties.24 In 2024 alone, over 150,000 Russians were given prosthetic limbs, with thousands more on the waiting list.25
Russian Adaptations
Despite a culture that punishes criticism,23 Russian forces have recently begun to recognize the poor condition of their tactical field care and taken steps to adapt. The Russian Ministry of Defense (MOD) recently created a Center for Tactical Medicine, a well-funded training program supported by some of the best physicians and medical facilities in the Russian Federation, that is specifically designed to teach Russian soldiers tactical medicine in the Ukrainian environment. Combat-experienced instructors train soldiers on tourniquet use, first aid, and even telehealth services. As part of this program, the Russian MOD has also focused on expanding the army’s supply of painkillers and tourniquets.24
While significant challenges persist for the Russian military – a June 2025 analysis suggested that the mortality rates for wounded Russian soldiers in Ukraine is still far higher than in Russian excursions in Afghanistan and Chechnya25 – it would be foolish to assume that Russian forces will not continue adapting.
Conclusion
In the current Russo-Ukrainian War, Russian forces have been hamstrung by poor combat medicine, specifically in the use of tourniquet control of hemorrhagic wounds. The Russian military has failed in both supply and training, as well as in setting an environment where criticism is met with punishment. Other militaries should learn from the poor example that the Russian Federation has set. However, this does not mean that Russian forces are out of the fight – the Russian MOD is currently engaged in an effort to modernize Russian tourniquet use and tactical medicine, which may increase Russian forces’ effectiveness in the coming years.
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