I sat the Diploma in Immediate Medical Care (DIMC but commonly shorted to Dip), in the summer of 2022. I found knowing where to begin revising quite a daunting process, so have put this guide together to hopefully help others prepare and be successful. This information is based purely on my experience of revising for the Dip and sitting it in the summer and is not endorsed by the Faculty of Pre-Hospital Care in any way.
So what exactly is the Dip?
I was told about the Dip when I was a 1st year student paramedic and it was described to me as learning how to provide gold standards of care. For me, that’s what it has been about, knowing that I am providing the best care I can to my patients. The studying I undertook enabled me to widen and deepen my knowledge base and fine tune my skills and I believe I practice at a higher level as a result.
The Dip is designed to “test the underpinning knowledge, technical skills and non-technical skills of doctors, nurses and paramedics who provide pre-hospital emergency care”. This is done through two elements, a written exam and an OSPE. The curriculum is vast, and the pass mark is higher than that associated with university courses, so it’s a highly regarded qualification. It’s often listed in the ‘desirable’ column of person specifications for HEMs/critical care paramedics and BASICs scheme positions and will be viewed positively on Pre-Hospital Emergency Medicine (PHEM) trainee application forms.
The pass mark varies with each diet (exam sitting) as a full psychometric analysis is undertaken after the diet to ensure each question or station has performed as expected. Typically the written is high 60s & the OSPEs is mid 70s. Historically paramedics have performed better in the OSPE than written and vice versa for the non-PHEM doctors. From 2014 – 2021, the pass rate for both elements according to profession was: PHEM trainee 99%, non-PHEM trainee 90%, paramedic 64%, nurse 73% (only 11 candidates). I’m not including these figures to put people off, but to demonstrate that there’s a reason this is a highly regarded qualification.
The Application Process
Candidates should have sufficient clinical experience (at the time of application) in the area of pre-hospital emergency care to have covered the relevant elements of the PHEM curriculum. The application form states at least four years post registration experience. Candidates can apply to the RCSEd for special consideration before then but this is not awarded without exceptional reason. The right time for you will depend on your individual knowledge and skills, your experience of working in the pre-hospital setting and what you have been exposed to. PHEM trainees also need to have five months whole time equivalent pre-hospital experience before sitting the exams. Most of the candidates are PHEM trainees and critical care paramedics, but there’s usually some non-PHEM trainee doctors, paramedics and a few nurses. The exams and marking system are the same for everyone, regardless of your profession.
Places are limited, so once the application process opens, apply early. You can choose to do the written and OSPE at the same time or separately. At the time of writing, the price for the exam is £760 (£325 for the written and £435 for the OSPE). https://www.rcsed.ac.uk/exams/exam-regulations?examdefid=a32d5b0d-17da-485e-a30f-2972fe6c4c4e&name=Diploma%20in%20Immediate%20Medical%20Care%20-%20Part%20A%20&%20B%20Components Anything relating to pre-hospital care provision can be tested, so make sure you give yourself enough time to prepare for it.
The Syllabus
The Syllabus is based on phase 1 elements of the PHEM curriculum which can be downloaded from http://www.ibtphem.org.uk. As you can see from the image, there are six specialty-specific themes as stated in the larger circles plus four cross-cutting themes. The exams test your knowledge of far more than just the medicine.
General Content
You’ll need to understand how emergency calls are answered, prioritised and resources dispatched. Can you use a radio and the phonetic alphabet? You need to know about the other health care professionals we work alongside, so read about their training, skill sets and regulatory bodies. Think about how other emergency services operate, their command structures and what medical capabilities they have.
What are the various methods of extrication and which options are suitable for various situations? There’s a fantastic recent Resus Room podcast discussing the latest research on this https://www.theresusroom.co.uk/courses/extrication/
Think about how we access various acute services other than the local ED. We all know our local PPCI and major trauma criteria, but are you familiar with which patients should go to a burns unit and which to a burns centre? When should they go to ED first? What about pregnant patients; when would you take them to an ED and when to an obstetric unit?
From a legal point of view, having a good understanding of consent and refusal of treatment is essential. Think about who can provide consent for a child, whether a child can refuse treatment, what if the parents don’t agree with your proposed treatment plan? If a patient has dementia does that mean they lack capacity to made decisions and give informed consent?
Are you familiar with how we store drugs in the pre-hospital setting, who can administer emergency treatment and which drugs are listed under the relevant sections of the Human Medicines Regulations?
What about exemptions when driving under blue lights? Everyone knows we can treat a stop sign as a give way, but can we legally drive at 60mph in a 30mph limit or park on zig zag lines? Can you remember all the different elements of the highway code?
With regards to major incidents, as a paramedic I was taught about the responsibilities of the first person on scene, how to provide a methane report, undertake triage and set up a CCS. By revising for the Dip, I learnt more about the roles of other emergency services, what the local authority are responsible for as well as increasing my knowledge of the JESIP principles and how they are put into practice.
Crew resource management (CRM) is another huge topic and within the OSPEs the examiners will see how you work within a team, how you delegate, how you recognise your own stress levels and those of others. Think about the different types of bias that can affect us, understand how to maintain situational awareness and know the common factors involved in adverse incidents.
Emergency Care
There’s a huge array of potential conditions that could be covered. I devised a list of common presentations and then added to it after reading the syllabus. Think about the signs and symptoms you’d see on assessment, what the differential diagnosis are, treatment (including pharmacology) and decision making regarding discharging on scene, referring to other agencies and best destinations if transporting.
Obstetrics & Care of the Newborn
Revise the normal anatomy and physiology changes that occur during pregnancy and the implications they might have when we’re assessing them and undertaking interventions. Know how to recognize and treat each condition.
I didn’t have any experience of dealing with major obstetric emergencies in the pre-hospital setting and hopefully most of us don’t. I recognised that gap in my knowledge, read around the subject and then did a course with the Great North Air Ambulance which gave me the opportunity to practice undertaking scenarios – more details at https://www.greatnorthairambulance.co.uk/training/ Please be mindful that this course hasn’t been officially endorsed by the FPHC for DIMC preparation, so please look at the course content and determine if it would be useful for you.
For newborns, understand the normal physiological changes that occur at birth, how we assess them, normal SpO2 levels, temperature control and what interventions may be required. There’s recently been a change in our guidance in caring for very preterm babies, so make sure you understand when we actively treat and when we are going to provide comfort measures. Obviously, you need to know the NLS algorithm.
Paediatrics
Again understand the A&P differences (including circulatory volume) and the differences within an A-E assessment. Learn normal vital signs and practice calculating the GCS for all age groups. There’s clear BTS/APLS/EPLS guidelines for managing asthma and read the NICE guidelines for feverish illness in under 5s, bronchiolitis and croup too.
ALS for Newborns, Children & Adults
Anything that is in the ALS manuals can be tested, not just the cardiac arrest algorithms. For special circumstances think about the adaptations needed for hypothermia, drowning and maternal arrests. For intraosseous access, cover indications, contraindications, landmarks, equipment, flow rates. Also understand when a resuscitation attempt wouldn’t be started, when it would be terminated and the actions that needed to be taken. There are clear guidelines in JRCALC.
Trauma
Trauma is obviously another huge topic. Understand the injuries that are likely to occur with different mechanisms, what we need to search for in our assessment, as well as the management of each type of injury. PHEM Cast have done two great podcasts discussing tension pneumothorax that are worth listening to and there’s a recent one by the Resus Room on pelvic fractures as well as extrication. Obviously read the FPHC Consensus Statements too.
Critical Care
Revise all elements of airway assessment and management, including capnography, difficult airway indicators, Cormack-Lehane classification and Difficult Airway Society guidelines. It’s important that we recognise situations when enhanced care teams are needed and know how we activate them. Undertaking Pre-Hospital Emergency Anaesthesia is a high-risk procedure, so as well as understanding when it’s indicated, we need to know the associated risks and complications. This includes post intubation checks, ventilator alarms, management of post PHEA hypotension. With regards to sedation, know the indications, drugs that can be used and the recommended standards of monitoring for sedation and anaesthesia. Also be familiar with the drugs that are used in the pre-hospital setting to manage post-anaesthetic complications such as hypotension.
The OSPEs
- 14 stations
- There may also be one or two rest stations
- 8 minutes for 12 stations, 16 minutes for the two ‘double’ stations covering trauma/life support
- Time includes 1 minute to read the information
- 25% of the entire exam relates to paediatrics
- Kit bags are provided
- Overall pass mark
The OSPEs take place in a large room which is partitioned by screens to make an individual station for each scenario. There’s a piece of paper pinned to the outside of the screen describing the scenario. When you go into the room, you’ll be positioned near your first station. As soon as you hear a bell, walk to your allocated station and immediately start reading the instructions. You have a minute to read and absorb the information. When you hear another bell enter the station and undertake the scenario. When you hear the next bell immediately leave and walk to the next station and start reading straight away. As you can imagine, it can be quite a noisy and warm environment.
The stations can relate to anything within the entire PHEM curriculum, so there’s obviously a huge array of possibilities.
The extended trauma and life support stations are double stations, so don’t panic when you hear the bell halfway through those – the examiners will provide clarification as needed.
The life support station could involve newborns, paediatrics or adults and will cover elements involved in a resuscitation attempt.
For the double length trauma station, it’s reasonable to assume you’ll be expected to undertake a thorough primary survey and required interventions. There could also be stations looking at individual elements of trauma management. Within the stations, explain your decision making behind conveyance decisions. It’s ok to say in my service this patient is major trauma positive due to XYZ, therefore I’m going to the MTC under blue light conditions with a pre-alert.
Other stations could include performing patient examinations e.g. limb injuries. Geeky medics have some videos that I watched during my training, so I used those within my revision. Make sure you know where to put ECG electrodes and are confident at interpreting ECGs, including all the different causes of ECG changes, not just ACS and PE. You may be asked to landmark on a person and then perform the procedure on a manikin. Sounds obvious, but make sure you can find the landmarks on real people. Some mannikins have a more pronounced angle of Louis compared to an actual human and my cricothyroid membrane definitely isn’t as large as on the sheep larynx that’s often used in training! There are great videos on IO insertion on you tube and different places also run surgical skills days that will give you the chance to practice undertaking these procedures.
Think about how you lead a debrief – there’s another good podcast from the resus room on this topic and also one on breaking bad news.
Are you confident talking to someone who has a mental health condition? Are you able to gain their trust so that they feel comfortable talking to you about sensitive matters? Do you know risk factors for suicide? Can you undertake a thorough capacity assessment?
Revise major incident management protocols and JESIP principles, practice undertaking a triage sieve & sort, giving methane reports.
OSPE Revision Tips
I’d mainly been responding as part of a team of two before I did the Dip, so I made sure I practiced being first on scene on my own or with a bystander. It’s really helpful to know the medical capabilities of other emergency service workers, as that will help you safely delegate tasks. Think about what you can ask family and members of the public to do and what you need to do yourself.
Get used to the equipment so it becomes second nature and you’re not having to concentrate too much on it. Learn how to apply KTDs, pelvic binders etc and then practice coordinating interventions to minimise patient movement and speed up the process until you’re really slick at it.
Be really confident delivering pre-alerts using ATMISTER. If you don’t do many, think about what you’d say for any patient even if they aren’t that unwell until you become really familiar with them. Go through the same with methane reports.
Tips for on the day
Wear loose, cool clothing that doesn’t identify wear you work or your job role. The examiner will only know your candidate number, not your professional background, so it’s important you’re not displaying your job role on your clothing. You don’t need to take any PPE – it will be provided if you’re expected to use it, so look around the stations. When I’m running teaching scenarios, people often miss actual hazards because they say ‘is it safe to approach’ as part of their OSPE ‘spiel’ without properly looking. Make sure you do look for hazards and act on what you see. Act as you would in real life: be polite, introduce yourself, reassure your patient, explain what’s happening and gain their consent. Ask about pain & discomfort and use pain scores before and after treatment.
Paediatric stations will have pre-printed sheets with drug doses on. I suggest learning the doses for some drugs though as it will save you time, eg salbutamol, ipratropium bromide, adrenaline for anaphylaxis.
Examiners may look ‘poker faced’ – that doesn’t mean you’ve done anything wrong! Examiners can’t provide any feedback to you during the exam, but if you get asked “Would you like to re-read the instructions for the station”, you should definitely take heed of that official ‘hint’!
For some stations you may finish early and that’s fine. You will need to remain in your station but take the opportunity to sit down for a minute, have a drink, try to clear your mind and breathe. The time is still yours to get marks – if you think of something else you want to do or say – do so!
When the bell rings immediately move on. Forget about what you did/didn’t do and focus on the next one, otherwise you could lose marks. There used to be a minimum pass mark for all stations, but now you just need to score an overall mark. So if one station doesn’t go as well as you planned, you can still pass if you score highly enough on the others.
Keep Calm!
This is an area I worked on having previously messed up a scenario because of nerves. It’s still a work in progress but I’ll share what I’ve learnt and do differently. High heart rates affect our thought process and ability to perform skills. Deep breathing can really help slow your heart rate down. Practice it regularly when you’re at difficult jobs and you may find you start doing it automatically when you become stressed. I did it whilst reading the information for the next scenario and it definitely helped. Many people suffer from Imposter Syndrome: work on building your self-confidence to help you have faith in yourself and your decision making. I know it’s easier said than done sometimes though!
It’s ok to take time out for a brief period to process your thoughts; try undertaking your primary survey, verbalising findings, allocating and undertaking tasks then repeat as needed.
Drink water that’s available if you’re thirsty – you do a lot of talking and may have a dry mouth from nerves!
The Written Exam
It’s 3 hours long & has 180 questions with 5 possible answers. Each answer may be correct, or at least plausible, but there will be only one ‘best’ answer. https://www.rcsed.ac.uk/view?id=29a3e5e0-a675-4931-89b3-efb776ab6c91&type=exam
I was told you don’t have time to think much as there’s so many questions, so I rushed through but actually didn’t need to. You’ll be able to answer some questions very quickly which will give you more than a minute to properly read and think about others. We’re always told to read questions carefully, but I know there was at least one I misread because I was rushing and got it wrong. If you’re undecided go with your instinct and worst case just make an educated guess as there’s no negative marking.
Reading List
- PHEM curriculum – http://www.ibtphem.org.uk
- FPHC consensus statements
- BTS, NICE & JRCALC guidelines
- Resuscitation Council UK ALS & EPALS/APLS (including NLS) course books
- ABC of pre-hospital care
- Oxford handbook of pre-hospital care
- Foundation Material for Immediate Care
- Major Incident Management
Other Resources
There’s lots of information on the NARU (www.naru.org.uk) and JESIP (www.jesip.org.uk) websites and I’d recommend watching their videos too. http://www.dontforgetthebubbles is a great resource for paediatrics and if you like podcasts the 2 paeds in a pod is useful too. I’m sure you’ve all heard of the Resus Room & PHEM cast podcasts but there’s also some good content on the General Broadcast and West Midlands Care Team as well. The Cambridge Pre-Hospital Care Programme has lectures every 1-2 months, with topics mapped to the PHEM curriculum. They can usually be viewed online – see @camprehosp or via facebook CamPreHosp. Regional FPHC groups also organise online lectures and events – more details via https://fphc.rcsed.ac.uk/about/regions and social media.
And Finally…
Remember the purpose of the Dip is for you to demonstrate you have the knowledge and skills to provide the highest standards of care. Share what you learn with your colleagues even if they aren’t doing the Dip and without giving away specific details, help others pass too. Ultimately this will improve the standard of care we provide and help motivate others to keep learning.
I hope you found this overview of my experience and preparation useful but please don’t take this as official guidance from FPHC. Any feedback via twitter @angcroucher. Good Luck!
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