Tourniquet application is a time-critical skill in the management of life-threatening exsanguination. Despite extensive use of tourniquets among military personnel, their use among civilian EMS providers is not well described. In January 2014, Los Angeles Fire Department (LAFD) began carrying combat application tourniquets. The objective of this study was to describe the experience of out-of-hospital tourniquet use in a large, urban, civilian EMS setting. A retrospective review of electronic patient records from January 1, 2014 to March 31, 2015 (18 months) from LAFD, the EMS provider for a city of 4.1 million, identified 93 cases of reported tourniquet use. Patient demographics, causes and location of bleeding, time to tourniquet placement, success in achieving hemostasis and level of provider placing the tourniquet were all recorded. Tourniquets were applied in 81 incidents. Mean age of the patients was 44 years (IQR 30, 56); 73% were male (n=59). 17% reported a history of diabetes, 16% established HTN, and 21% chronic renal insufficiency. 41% were dispatched as BLS level of service and 59% as ALS; whereas in the field, based on local policy, 19% met criteria for BLS transport and 81% required ALS transport. Median time from patient contact to tourniquet placement was 5:00 minutes (IQR 2:00, 11:00), and median time from patient contact to leaving scene was 10:01 minutes (IQR 6:47, 14:58). 63% of incidents were due to penetrating trauma, 11% blunt trauma, 25% were due to bleeding dialysis access sites, and 1% were due to other sources of bleeding (eg, bleeding abscess). 79% of tourniquets were placed on an upper extremity, 20% on a lower extremity, and 1% on both an upper and a lower extremity. 11% of tourniquets were initially placed by bystanders, whereas 88% were placed by EMS personnel (of which 7% were placed by EMTs and 93% by paramedics). Hemostasis was achieved with the tourniquet in 77 (95%) of cases. Two patients (2.5%) suffered an out-of-hospital cardiopulmonary arrest: one due to exsanguination from a bleeding dialysis shunt who successfully achieved hemostasis with a tourniquet and subsequently regained pulses, and another who suffered a traumatic arrest due to gunshot wound to an extremity, had no out-of-hospital ROSC and subsequently died in the ED. Sixty-two (77%) were transported to a trauma center. Out-of-hospital tourniquets were applied most often for penetrating trauma patients and bleeding dialysis shunts in this urban civilian EMS system with rapid achievement of hemostasis in almost all cases. Tourniquets should be widely available to all EMS providers.