Prolonged field care on high-intensity battlefields: stabilization protocols for polytraumatized patients under evacuation-chain disruption

For two decades the western combat-casualty paradigm has rested on the so-called golden hour: the assumption that a wounded service member can be evacuated to a Role 2 or Role 3 surgical facility within sixty minutes of point of injury. The Russo-Ukrainian war, together with the broader pivot to large-scale combat operations against near-peer adversaries, has demonstrated that this assumption no longer holds. Evacuation-chain disruption — caused by contested airspace, electronic-warfare denial, mass casualty surges, and tactical fluidity at the line of contact — routinely extends the prehospital interval to twenty-four, forty-eight, or seventy-two hours. Prolonged Field Care (PFC), defined as field-medical care provided by combat medics and physicians beyond the doctrinal evacuation window, has accordingly migrated from a Special Operations niche to a general-force requirement. This article is written in early 2024 with the benefit of two campaign years of evidence from Ukraine and the consensus update of the Committee on Tactical Combat Casualty Care, and it addresses a specific gap in the existing literature: although consensus guidelines for prolonged casualty care have matured between 2017 and 2023, no validated bedside scoring instrument exists to track the stabilization status of a polytraumatized patient across the multi-domain interventions that PFC requires. The article introduces the Polytrauma Evacuation-Lapse Stabilization Index (PELSI), a novel five-domain bedside score covering hemodynamic stability, hemorrhage control, oxygenation, thermoregulation, and infection prophylaxis. Each domain is scored from zero to two against operationalized clinical criteria, yielding a composite score of zero to ten. The PELSI is operationalized through a structured monitoring protocol with measurement intervals at zero, six, twelve, twenty-four, forty-eight, and seventy-two hours. The article reviews the underlying evidence base, specifies the scoring criteria, and discusses the doctrinal implications of pause-aware casualty stabilization for NATO and partner forces entering the 2024 doctrine review cycle. Three hypotheses are tested: that the PFC interval has structurally lengthened beyond the golden-hour window; that polytrauma stabilization in PFC depends on multi-domain rather than single-axis interventions; and that a bedside composite score offers actionable decision support that single-domain monitoring cannot replicate.