When medical treatment begins on service members during combat operations, the most important hour in their life begins—the golden hour. The clock starts when medical care begins at the point of injury and ends when service members receive surgical treatment at a military hospital in theater, Europe, or back in the United States. Their survival rate increases substantially when the golden hour is not surpassed.

U.S. Army medics and U.S. Navy corpsmen understand the importance of the golden hour because they are trained to provide critical care immediately in the harshest conditions. However, for military personnel who recently decided to serve as surgeons, doctors, nurses, physician assistants, dentists, and other medical specialists, providing medical care in combat situations are unfamiliar at best.

The Combat Casualty Care Course, otherwise known as C4, is a four-day immersion into combat medicine, preparing military medical officers for duties in the Defense Health Agency’s hospitals, dental clinics, and to perform life-saving measures during combat operations and mass casualty events.

U.S. Air Force Maj. Simon Domenech, a physician’s assistant at Reid Clinic, Lackland Air Force Base, Texas, with multiple deployments spanning his 19-year career, found the training realistic and challenging.

“C4 puts individuals in a position in which they are not comfortable and that’s where growth begins, particularly for those with less experience in those [combat] environments,” said Domenech, who deployed to Afghanistan multiple times during Operation Enduring Freedom.

Students are exposed to simulated mission-oriented medical scenarios including village stability operations, mass casualty events, military operations on urban terrain, and a simulated field hospital using state-of the-art simulator technology. They also experience combat scenarios to test leadership in various roles while participating in planning and executing a medical mission.

U.S. Army Sgt. Shawn Collins, a C4 instructor since 2019, said students see a different side of military medicine that comes with its own unique challenges. For most of them, this is their first exposure to combat medicine.

“Ninety percent of our student body are interns or residents, said Collins, who was a senior line medic with the 1-2 Stryker Brigade Combat Team, Joint Base Lewis-McChord, Washington, before joining the Defense Medical Readiness Training Institute’s Combat Medicine Branch. “Their experiences in the military have been through their medical departments and specialties. They come here with no prior experience in pre-hospital care.”

By completing the course, students become certified in their appropriate professional level–Advanced Trauma Life Support, Trauma Nurse Core Course, or Pre-Hospital Trauma Life Support. Although that certification ensures patients receive safe, quality health care in DHA’s hospitals and clinics, it is the tactical combat medical skills and leadership they learn that ensures military readiness when service members need it most.

According to U.S. Navy Lt. Richard Gonzales, combat medicine branch officer-in-charge of the Defense Medical Readiness Training Institute in Joint Base San Antonio, Texas, students test the skills and knowledge learned through tactical combat casualty care phases, including care under fire, tactical field care, and tactical evacuation care.

“The last three days of the C4 course puts all of it together with the students going through practical training as well as getting placed in combat and mass casualty scenarios,” said Gonzales, a health care administrator with 25 years of service. “We run the students through a point of injury simulation where they must conduct care under fire with full gear and transition to tactical field care.”

After successful completion of C4, students receive the National Association of Emergency Medical Technicians TCCC Certification, which is the only TCCC course endorsed by the American College of Surgeons.

“They now understand what it’s like to care for patients in the rocks and dirt and why patients come in the way they do,” Gonzales said. “When bullets are flying overhead, the strategy changes because patient care must be provided in difficult situations, not in a controlled, safe environment. It enriches their experience and perspective while developing muscle memory in chaotic situations.”