A standardized training program of “intelligent sensor-equipped simulator+animal model” for resuscitative endovascular balloon occlusion of the aorta enhances combat casualty care capability of frontline military physicians: a self-controlled before-and-after trial

On the land battlefield, non-compressible torso hemorrhage is the leading cause of preventable death from combat injuries, yet frontline military physicians generally lack effective endovascular hemostatic skills. This study aims to develop a standardized training program for resuscitative endovascular balloon occlusion of the aorta (REBOA) by combining intelligent sensor-equipped simulation manikins with animal models, and to verify its efficacy in improving REBOA proficiency among frontline medical physicians with no prior interventional experience, with a goal of addressing the bottleneck in extending advanced combat casualty care to the frontline.

A self-controlled before-and-after study design was adopted. Twenty on-duty primary-level military physicians from the Army (representing 18 brigade- and regiment-level medical units) were enrolled in June 2023. The participants first completed 10 full-procedure practice sessions on an intelligent simulator to establish skill acquisition curves; subsequently underwent stepwise reinforcement training in femoral artery puncture and catheterization using 10 experimental pigs (weighing 30 to 40 kg); and finally, were assessed using 10 porcine hemorrhagic models (weighing 30 to 40 kg). Digital subtraction angiography (DSA) was applied to observe the accuracy of balloon position. Training effectiveness was evaluated by comparative analysis of trainees’procedural time at different stages of simulator practice, puncture time and procedural success rate during REBOA training on the porcine model, as well as puncture time, balloon positioning accuracy, procedural success rate, and complications during assessment on the porcine hemorrhagic model.

All the 20 trainees successfully completed the training. ① Skill acquisition efficiency: During the simulator training phase, the single-operator procedural time was decreased from 10.8±1.2 min at the first attempt to 5.3±0.4 min at the tenth attempt (P<0.001); The goodness-of-fit of the single-phase decay model was R²=0.98, indicating that skill plateau was reached after the 7th practice session. ② Real-world transfer capability: The trainees completed stepwise skill intensive practice on live experimental pigs, with a mean femoral artery puncture duration of 4.8±1.2 min and a success rate of 95% (19/20); Under DSA fluoroscopy guidance, the mean time for balloon positioning at aortic Zone Ⅰ (timed from balloon entry into the arterial sheath) was 3.8±0.9 min, with a success rate of 95% (19/20). In the assessment on the live porcine hemorrhagic model, the average total procedure time was 7.8±1.4 min (95%CI: 7.2 to 8.4); 19 out of 20 trainees (95%) achieved visual confirmation of successful hemostasis of the contralateral femoral artery. ③ Safety: The complication rate during the assessment phase was 10% (2/20), and the overall pass rate in the final comprehensive evaluation reached 90% (18/20).

Junior military physicians with no prior interventional experience can acquire preliminary proficiency in REBOA technique through the training program of intelligent sensor-equipped simulator combined with animal model; This program provides a replicable training pathway for disseminating REBOA technology to grassroots units.