Whole Blood Training Program in the Bundeswehr Medical Service – Concept, Implementation, and Qualification Profile

Martin Teufel^a, Diana Sauer^b, Christoph Jänig^c, Jens Prein^d, Tobias Markmeyer^d, Jan Ammann^e

^a Training and Simulation Center, Medical Regiment 3 Dornstadt

^b Department of Transfusion Medicine, Bundeswehr Central Hospital Koblenz

^c Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy, Bundeswehr Central Hospital Koblenz

^d Rapid Deployment Medical Command Leer

^e Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy Bundeswehr Hospital Ulm

Summary

Trauma-related hemorrhage remains one of the leading preventable causes of death in both military and civilian settings. Logistical constraints, longer evacuation times, and limited infrastructure can significantly restrict the availability of component-based blood products, especially in deployed military environments. In this context, structured whole blood transfusion strategies are becoming increasingly important. The Bundeswehr Medical Service has developed a standardized, team-based training program for whole blood donation and transfusion. The program trains physicians and selected non-physician medical personnel to collect, process, and administer whole blood in operational conditions, in accordance with transfusion law. The curriculum is simulation-based, competency-oriented, and fully integrated within the regulatory framework. This article describes the legal background, training structure, exam procedures, and qualification requirements, and places the concept within the broader scope of military medicine.

Keywords: whole blood; emergency transfusion; military medicine; hemotherapy; training; transfusion law; simulation-based training

Introduction

Uncontrolled bleeding remains one of the most common preventable causes of death in both military and civilian settings [5][10]. Early hemotherapy is a key part of damage-control resuscitation (DCR) and greatly affects morbidity and mortality [9]. Whole blood includes erythrocytes, plasma, and, depending on the manufacturing process, platelets in a physiological ratio, and it is considered a first-line treatment in tactical medicine according to current guidelines [12]. The organized use of whole blood is therefore becoming increasingly important in both military and civilian environments [3][11], including in Germany [7][8].

Internationally, the adoption of whole blood programs in civilian emergency medicine is being actively encouraged. Notable examples are the Norwegian Blood Preparedness Project [1] and the whole blood program of Royal Caribbean Cruise Lines [6].

Blood donations and transfusions in Germany are governed by the binding requirements of the Transfusion Act and the Hemotherapy Guidelines of the German Medical Association; this is also fully applicable in the military sector.

In response, the Bundeswehr Medical Service has created a standardized, multidisciplinary training program for whole blood donation and transfusion to enable personnel with diverse qualifications to collect, process, indicate, and administer whole blood in compliance with regulations. This article outlines the structure, content, and qualification framework of this training and situates it within the context of military medical and transfusion law.

Legal Framework and Conditions

The conduct of blood donations, transfusions, and the use of blood products are thoroughly regulated by law in Germany. Even in the military context, the collection, production, and use of blood products must comply with civil legal standards. The purpose of these legal norms, guidelines, and regulations is to ensure the highest level of safety for both donors and recipients of blood products.

For the Bundeswehr Medical Service, it means the obligation to follow the core principles of quality, safety, and traceability even during operations. Training for whole blood donation and transfusion is therefore consistently aligned with recognized standards of transfusion medicine and the relevant official requirements.

Training

Overview

The goal of the training is to provide participants with the necessary theoretical knowledge and practical skills to safely perform an emergency transfusion or blood donation, including the production of a transfusion-ready whole blood unit. Participants also gain insights into organizational and structural quality assurance processes and are trained on safety issues related to whole blood products, including relevant infectious factors. A key aspect of the training is its interprofessional approach. The certification for collecting and using whole blood is not limited to medical personnel; it has been extended to qualified non-medical staff under specific legal and professional conditions. This ensures the availability of whole blood even during extreme operational circumstances.

The following groups are generally eligible for the “Whole Blood Donation Practitioner” training.

• Medical personnel,
• specially qualified nurses for anesthesia and intensive care,
• specially qualified emergency medical technicians, and
• specially qualified deployment paramedics (especially Combat First Responder C or similar qualifications).

With the revision of the procedural instruction for collecting and using whole blood in Bundeswehr military operations in 2026, emergency nursing staff will also be included.

The qualification’s validity is limited to 36 months for medical personnel and 24 months for all other participants.

In 2022, initial pilot trainings for practitioner development took place, initially for special and specialized forces of the Bundeswehr. Building on these experiences, the Expert Working Group on Whole Blood at the Training and Simulation Center of Medical Regiment 3 developed the curriculum “Whole Blood Donation Practitioner” in 2023, which was then tested in a pilot phase. Since 2024, the training has been part of the official Bundeswehr training catalog.

In 2025, a compressed two-day training variant for anesthesiology specialists with continuing education as transfusion officers was established. The performance evaluations are identical in content and form to those of the regular practitioner training. Additionally, a curriculum-embedded e-learning format is used.

So far, approximately 260 individuals have completed the regular practitioner training, from sergeant to senior medical officer. Of these, 27% were medical personnel and 73% were non-medical personnel. The average pass rate was nearly 87% (n=226). Twelve specialists completed the shorter training version with a 100% pass rate.

Practitioner Training

The training is based on the theory of experiential learning according to Kolb [2] and is consistently simulation-based. The goal is to develop operational security under realistic conditions. Additionally, an e-learning module built on Moodle was implemented via the Bundeswehr “link&learn” platform. Providing teaching materials, supplementary literature, and instructional videos significantly enhanced the theoretical foundational understanding of non-medical participants. The preparatory learning phase ends with a mandatory online pre-test. Although the result is not a formal requirement for participation, it enables differentiated learning-group analysis and targeted adjustments to classroom instruction.

The week-long classroom phase includes 16 theoretical units and 15 practical training units in small groups. The training ends with an individual exam before a panel, comprising written, practical, and oral components. The total time commitment is approximately 2 to 2.5 hours per participant.

Theoretical Training Content

Theoretical instruction covers, among other aspects:

• Physiology of hemorrhage and shock, including basics of hemostasis and coagulation diagnostics.
• Blood products and coagulation-modulating drugs, as well as concepts of massive transfusion.
• Immunohematology, including blood group characteristics (ABO, Rhesus, Kell), blood typing, and clinical-chemical diagnostic procedures, including sample shipping and transport.
• Transfusion-relevant infectious diseases, including diagnostic procedures, risk assessment, transfusion reactions, and management of adverse events.
• Algorithm-based indications for (massive) transfusions.
• Donor selection and guideline-compliant blood donation, including performance capacity post-donation.
• Documentation on both donor and recipient sides.
• Legal foundations, including relevant guidelines, recommendations, and documentation requirements.
• Logistics and proper handling of blood products (component-based products and whole blood).

The theoretical training starts with the e-learning phase, then moves to classroom instruction in a closed seminar room. The practical training is closely connected to the theoretical modules and gradually increases throughout the course. Starting on the third day, the focus shifts to scenario-based execution of the entire process – from indication to transfusion. Practical training takes place in small groups of three to four soldiers, each with an instructor. The instructor ratio is one medical and one non-medical instructor for every six participants (Figure 1).

Fig. 1: German soldier performing a whole blood donation during training, shown at the start of leukocyte depletion after blood collection (Source: Bundeswehr Media Database)

Practical Training Content

Practical training includes the following steps:

• indication based on the existing algorithm,
• determination of ABO, Rhesus, and Kell blood groups on the recipient’s side, including the use of commercially available bedside tests,
• subsequent donor selection, donor history, counseling, and assessment or determination of suitability for blood donation, including prioritization of donors in mass casualty incidents,
• performing whole blood donation, including collection of reserve samples,
• diagnostics for HIV, hepatitis B and C, and syphilis, including rapid test-based infection serology as point-of-care diagnostics,
• determination of ABO, Rhesus, and Kell blood groups on the donor’s side, including the use of commercially available bedside tests, and
• leukocyte depletion and the production/labeling of the final transfusion product, including documentation on both donor and recipient sides, as well as
• transfusion of the finished whole blood product after blood group confirmation.

Participation in puncture is voluntary only. The maximum donation limit is 150 ml per person. Autologous retransfusion is not performed. The training uses the current blood donation systems (Figure 2).

Fig. 2: Material overview of whole blood donation showing the donor, recipient, test components, and the prepared system, including a puncture simulator and artificial skin (Source: Bundeswehr, A. Schmidt)

Simulation and Scenario Training

The training is conducted using prepared blood donation systems. The fill weight is continuously monitored with a spring scale (target value: 475 g ± 10%) to ensure realistic product quality.

In simulation-based training and assessments, it is important not only to provide a realistic puncture experience but also to realistically vary or control both the blood flow rate and the duration of filtration (leukocyte depletion). Accurately representing the puncture site on living humans is important but challenging. The use of large-bore donation needles significantly limits the usability of IV skill trainers, as they cannot be sealed after puncture and can only be used once. To address this, a cost-effective, safe puncture simulator was developed using standard cross-sectional items and leftover materials, combined with homemade artificial skin, offering an inexpensive and realistic simulation option. By utilizing polyethylenglycol (PEG) bags as artificial blood supplies, any donation volume and duration can be realistically simulated using commercially available products. Developing artificial blood recipes based on commercially available components allows for the realistic mimicking of blood behavior during leukocyte depletion, including temperature- or environment-dependent changes, enabling filtration intervals of 12 to 25 minutes to be reliably simulated.

Therefore, on the third day of training, participants focus almost entirely on practically implementing the entire process, from indication to donor selection and examination, counseling, whole blood donation, and the initiation of transfusion. After practicing individual steps or working in a controlled classroom environment during the previous two days, the third training day takes place under realistic conditions. The training is conducted in full combat gear, typically outdoors. The goal is to prepare participants to be ready for transfusion within 45 minutes of initial contact with the donor. During this session, 12 participants are trained and evaluated by 4 instructors.

Examination Procedures

The assessment of the training is conducted similarly to the practical exam, using a standardized test form that covers all individual activities of the entire process in 30 steps. Errors are categorized into three groups:

• red: immediately life-threatening (e.g., major incompatible transfusion),
• yellow: indirectly threatening but not immediately life-threatening,
• green: minor errors.

Four errors within one category equate to one error in the next higher category.

On the following training day, participants undergo individual assessments. This exam is a vital part of the training to ensure and showcase the high quality of future practitioners’ skills. Examinations are performed in written, oral, and practical formats before an examination board composed of two equal examiners, one medical and one non-medical instructor. If the examiners cannot agree on the evaluation, the practical exam must be repeated before three examiners. This situation has not yet happened.

The written exam lasts 60 minutes and includes 40 multiple-choice questions, with a passing threshold of 75%. The practical exam follows, with the same time limit of 45 minutes, from donor contact to transfusion readiness. The exam is considered failed if there is one red error. The oral exam takes place shortly after the practical exam. Participants answer 25 questions covering various course topics, and the exam lasts approximately 30 minutes. The same evaluation standards apply as in the written exam. Grading is on a scale of 1 to 6, with a minimum average grade of 4.49 needed to pass. The written and oral grades can compensate for each other. The practical exam is a barrier subject, meaning a result of at least 4 is required to pass. With excellent scores, an Instructor Potential (IP) is awarded, qualifying participants for further instructor training or required for it. To earn the IP, none of the three partial grades can be worse than 2, and the overall score must be 90% or higher. The IP must be confirmed by both examiners and emphasizes solid answers or a deep understanding of the topics (Figure 3).

Fig. 3: New algorithm for whole blood donation presented as a pocket card (Source: Bundeswehr, procedural instruction whole blood)

Participants’ learning progress can be objectively measured based on the results of the pre-test and final exam (n = 266). The performance development aligns with the subjective satisfaction of the participants. Since 2025, a shortened training format with a total duration of two days has been offered for specialists in anesthesiology with completed further training as transfusion officers (specialist knowledge in transfusion medicine). This allows key personnel with high routine and expertise to be less burdened by absences. Participants have access to the same self-paced e-learning; along with the high level of training, the theoretical training is reduced to the necessary minimum of two teaching units in favor of practical training. To maximize practical training time, the exam is conducted by three examination boards with six participants each. This arrangement, along with the parallelization of the written and practical-oral components in two exam groups, limits the total exam time to three hours. The modalities of the final exam are identical to those used in regular practitioner training.

Instructor Training

Despite the challenges brought by the SARS-CoV-2 pandemic, a one-week instructor training by the Expert Working Group on Whole Blood at the Bundeswehr Central Hospital in Berlin started after a pilot phase in 2021. During practitioner training and the new training priorities, the previous instructor training was assigned to the Training and Simulation Center of Medical Regiment 3 in 2023, where it was adapted both structurally and content-wise, and continued.

The instructor training follows, similar to internationally validated training formats, two modules: Module 1 “Preparation Course” and Module 2 “Mentoring.”

Module 1, the “Preparation Course,” involves a training week covering the planning, organization, and execution of practitioner training, as well as training content, teaching methods, and guidelines for consistent, standardized training. It requires teaching samples and intensive practical training focusing on teaching, assessment, didactic skills, team leadership, and evaluation and improvement. The module ends with a comprehensive assessment; a formal exam is not included.

Module 2, “Mentoring,” takes place within six months of Module 1 at the latest and lasts one week. Under the supervision of experienced instructors at the Training and Simulation Center of Medical Regiment 3, candidates independently conduct at least one “Whole Blood Donation Practitioner” course. Similar to Module 1, there is no final exam, but a comprehensive evaluation.

To qualify as an instructor for whole blood donation, one must complete both modules. This qualification is valid for 24 months and is available to both medical and non-medical personnel. The teaching qualification is maintained through active instructor involvement; within 24 months, at least two regular practitioner courses must be conducted. The qualification is renewed by extending the practitioner certification.

Conclusion

The implementation of a structured whole blood program addresses the urgent treatment of life-threatening bleeding in logistically constrained situations. The interprofessional approach greatly expands operational capabilities without compromising regulatory safety standards. The presented concept combines operational flexibility with transfusion law compliance and offers a structured, quality-assured model for military deployment. The Bundeswehr Medical Service is the only national institution [4] that provides and promotes this capability. This opens opportunities for further international and civil-military cooperation in military and disaster medicine.

Key Statements

• Traumatic hemorrhage is one of the leading preventable causes of death in military operations.
• Whole blood allows for logistically practical emergency transfusions, even in resource-­limited settings.
• The training is interprofessional, simulation-­based, and consistently aligned with transfusion law requirements.
• Medical and non-medical personnel are trained and qualified for application.
• The concept combines regulatory safety with operational effectiveness.

References

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Conflict of Interest Statement:

The authors declare no conflict of interest in accordance with the guidelines of the International Committee of Medical Journal Editors.

Manuscript Data

Citation

Teufel M, Sauer D, Jänig C, Prein C, Markmeyer T, Ammann J. Whole Blood Training Program in the Bundeswehr Medical Service – Concept, Implementation, and Qualification Profile. WMM 2026;70(5E):6.

DOI: https://doi.org/10.48701/opus4-882

For the Authors

Lieutenant Colonel (MC) Martin TEUFEL

Training and Simulation Center Sanitätsregiment 3

Auf dem Lerchenfeld 1, D-89160 Dornstadt

E-Mail: martinteufel@bundeswehr.org