Clinical decision making: DipIMC practice questions
PHEM curriculum unit B.3 · Cross-cutting theme B: Team Resource Management
The DipIMC is blueprinted against phase 1 of the UK Pre-hospital Emergency Medicine (PHEM) curriculum. This page covers unit B.3, Understand and apply principles of decision making.
Below are 3 free practice questions from the DipIMC.Ninja bank, in the Part A single best answer format. Every answer names the textbook page, guideline or statute it was written from, so you can check it rather than take it on trust. The bank holds 7 questions on this unit.
Question 1 · Law, Ethics & Human Factors · Hard
A helicopter emergency medical service (HEMS) team is with a 40-year-old cyclist who has been struck by a car. He is hypotensive and tachycardic, a pelvic binder is on, and the team has already decided to take him to the major trauma centre 15 minutes away. The doctor has a handheld ultrasound device and proposes to complete a full extended focused assessment with sonography in trauma (eFAST) on scene, including a search for free intraperitoneal fluid, before the patient is moved. According to the FPHC consensus statement on pre-hospital ultrasound, which is the most appropriate approach?
AComplete the full eFAST on scene and divert to a general surgical unit if it is positive
BComplete the full eFAST on scene and downgrade the pre-alert if the abdomen is negative
CComplete the full eFAST on scene, then repeat the free-fluid views at intervals en route
DScan on scene only for a focused question that alters management; do the rest in transit
EDefer all ultrasound, including any focused scan, until arrival at the receiving hospital
Show answer
Answer: D
Scan on scene only for a focused question that alters management; do the rest in transit
The first recommendation of the FPHC pre-hospital ultrasound consensus is that clinicians should only use pre-hospital diagnostic ultrasound to answer a focused question where the answer will alter pre-hospital management, and not delay time-critical interventions. The statement adds that examinations which may not affect on-scene management — it gives scanning for intra-abdominal free fluid as the example — are feasible to perform in transit. Here the destination is already decided and an abdominal finding would not change it, so the free-fluid search is no reason to stay on scene; it can be done en route. Diverting on a positive scan reverses the decision already made. A negative eFAST should not be used in isolation to guide management, and pre-hospital diagnostic accuracy is inferior to hospital studies, so downgrading the pre-alert on a negative scan is unsafe. Scanning on scene and then again in transit adds scene time for no change in management. Deferring every scan goes beyond the consensus, which supports focused scans that change management. NICE NG39 is consistent: consider eFAST only to augment clinical assessment and only if onward transfer will not be delayed, and a negative focused assessment with sonography in trauma (FAST) does not exclude intraperitoneal or retroperitoneal haemorrhage.
Pre-hospital Ultrasound Consensus StatementFaculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh·Recommendation 1: examinations feasible in transit“intra-abdominal free fluid) and are feasible to perform in transit”Open PDF at page 4
law-075 · Law, Ethics & Human Factors · Human Factors · Hard · v3
Question 2 · Law, Ethics & Human Factors · Moderate
A BASICS doctor is treating a trapped driver on the hard shoulder of a motorway at night. The live lanes have not been closed, traffic is passing at speed within a few metres, and the fire and rescue service says a rolling road block cannot be obtained for at least 20 minutes. The doctor works through the dynamic risk assessment model described in the ABC of Prehospital Emergency Medicine and concludes that the risk to the team is not proportional to the benefit and that no additional control measures can be introduced. What does the model require the doctor to do?
AContinue treating under the scheme's generic risk assessment for motorway working
BContinue treating the driver and accept the risk to the team as part of the duty of care
CStop the activity and withdraw the team from the hard shoulder to a place of safety
DHand the decision to continue or withdraw to the fire and rescue incident commander
EContinue treating and document the risk and the decision on the patient report form
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Answer: C
Stop the activity and withdraw the team from the hard shoulder to a place of safety
The ABC sets out dynamic risk assessment as a loop (Figure 36.3): evaluate the situation, tasks and persons at risk; select the tasks and system of work; then assess whether the risks are proportional to the benefits. If they are, continue. If they are not, ask whether additional control measures can be introduced: if they can, re-assess the system with them in place; if they cannot, stop. This doctor has answered both questions 'no', so the model ends in STOP. Generic risk assessments, produced in advance for common scenes such as high-speed roads, identify control measures and shape training, but the book is explicit that they do not, by definition, cover every incident scene, which is why dynamic risk assessment, the continuous assessment of risk in a rapidly changing environment, is needed. A generic assessment therefore cannot override a dynamic finding of disproportionate risk; the model leaves no route by which a duty of care, a decision passed to another agency, or documentation alone allows the activity to continue.
Where this comes from
ABC of Prehospital Emergency Medicine
Ch. 36 Clinical Governance · Risk management: dynamic risk assessment (Fig. 36.3) · p. 199“Assess the system-are risks proportional to benefits?”
Ch. 36 Clinical Governance · Risk management: dynamic risk assessment (Fig. 36.3) · p. 199“Can additional control measures be introduced?”
Ch. 36 Clinical Governance · Risk management: generic risk assessment · p. 199“Generic risk assessments do not, by definition, cover every incident scene”
Ch. 36 Clinical Governance · Risk management: dynamic risk assessment · p. 199“Dynamic risk assessment is the term used to describe the continuous assessment of risk”
law-076 · Law, Ethics & Human Factors · Human Factors · Moderate · v2
Question 3 · Major Incident & Triage · Hard
You are the medical adviser at the tactical command point of a multi-agency incident in which part of a building has collapsed with people inside. The picture is changing minute by minute. A newly qualified ambulance commander is being told by a colleague that every stage of the JESIP Joint Decision Model must be worked through, in order and in full, before any action can be authorised. Which statement best reflects how the Joint Decision Model is intended to be used?
AStrict adherence to it is secondary to achieving the desired outcomes, especially as things change fast
BEach of its five stages must be completed and recorded in sequence before any action is authorised
CIt applies only once a major incident has been declared and an M/ETHANE message has been sent
DIt is worked through once at the start, to set a plan that all agencies then follow until stand-down
EIt is a police decision tool that the ambulance service adopts only when the police are the lead service
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Answer: A
Strict adherence to it is secondary to achieving the desired outcomes, especially as things change fast
The Joint Decision Model was developed so that commanders from different organisations can bring together the available information, reconcile objectives and make effective joint decisions. The Oxford Manual of Major Incident Management is explicit that strict adherence to the model must be secondary to the need to achieve desired outcomes, especially in rapidly changing situations, which is exactly the position of this commander. It is a cycle, not a checklist: its final stage is to take action and review what happened, which returns the commander to gathering information as the picture changes, so a plan set once and followed unchanged, or a rule that every stage must be completed and recorded before acting, both misread it. JESIP's approach is not confined to declared major incidents; the Oxford Manual notes that it can be applied to small-scale incidents, wider emergencies and pre-planned operations. Nor is the model owned by the police: it is a joint model for all the emergency services, although one service will usually act in a lead capacity for co-ordination, usually the police. Documenting decisions still matters, but the model does not require every stage to be completed before acting.
Where this comes from
Oxford Manual of Major Incident Management
Ch. 1 An Introduction to Major Incident Management · Joint Emergency Services Inter-operability Programme (JESIP): Joint Decision Model · p. 16“Strict adherence to the JDM must be secondary”
Ch. 1 An Introduction to Major Incident Management · Joint Emergency Services Inter-operability Programme (JESIP): Joint Decision Model · p. 16“This approach can be applied to small-scale incidents, wider emergencies, and pre-planned operations.”
Ch. 1 An Introduction to Major Incident Management · Joint Emergency Services Inter-operability Programme (JESIP): Joint Decision Model · p. 16“The lead service will usually be the police service.”