10 POISON CENTRE STAFF TRAINING AND QUALITY
10.3 TRAINING OF MEDICAL TOXICOLOGISTS
DOCUMENTATION
Poisoning cases must be accurately, consistently documented. This is often a requirement for medico- legal reasons and is also important for epidemiological research, toxicovigilance, collection of follow-up data and compiling statistics. Each centre has its own method for recording enquiries, usually in a computer database. Enquiries may be logged live, as the call is taking place, or initially recorded on paper and the information entered into a database at a later stage, ideally soon after the enquiry is complete.
Trainees should be shown how to complete the enquiry record accurately, ensuring that the document is clear, scientifically accurate and completed in a timely manner. Training should include an explanation of the reasons for entering particular information and the importance of an accurate, complete record of each case.
10.2.2 ASSESSMENT AND EXAMINATION
After completion of the training programme, the poisons information centre should have some form of assessment of trainees’ skill before they answer calls unsupervised. This is important for clinical governance. The competence of trainees can be assessed by:
• a formal examination;
• a detailed checklist that indicates a minimum level of competence in each training objective; or
• by setting a threshold number of calls or of calls about specific poisons that the trainee has to answer while under supervision.
The training period may be regarded as a probation for the new member of staff until they are certified as competent by the assessment method selected. Once trainees are established as competent, they will be able to participate in the staff rota and answer telephone enquiries unsupervised.
PART I
1. General principles of medical toxicology Type and circumstances of poisoning:
• acuity of poisoning (acute, subacute, chronic)
• type of poisoning: deliberate (suicidal, criminal, dependence, abortion) or unintentional (home, workplace, environmental)
• poisoning epidemics
• groups at risk (children, older people, pregnant women, specific occupations)
• adverse drug reactions
Basic principles of toxicology and toxinology:
• toxicodynamics (mechanisms of toxic action)
• toxicokinetics (metabolism)
• experimental data and evaluation
• toxicity testing
• routes of exposure
• carcinogenesis
• teratogenesis
• genetic toxicology Clinical diagnosis:
• clinical aspects
• toxic syndromes
• differential diagnosis
• role of analytical services
General principles of treatment of poisoning:
• first aid and decontamination
• resuscitation and stabilization
• prevention of absorption
• enhancement of elimination
• symptomatic and supportive treatment
• antidotal and antivenom therapy
Organizations and groups with a role in poison control programmes:
• poison control centres
• governmental and regulatory authorities
• universities
• experimental toxicologists
• other research groups concerned with assessment of human toxicity
2. Human toxicology of specific substances: Systematic study of the most common and important causes of, and substances involved in, human poisoning:
• medical products
• industrial products
• pesticides and other agricultural products
• household products
• poisonous plants and fungi
• poisonous and venomous animals
• environmental pollutants
• food poisoning
For each substance, the following should be considered: main use, physical and chemical properties, kinetics, metabolism, mode of toxic action, toxicity data, laboratory data (for example, toxic levels), pathology, symptomatology, diagnosis, treatment, carcinogenicity, teratogenicity, legal aspects, prevention, particular aspects of acute and chronic toxicity, long-term effects.
PART II
• Human toxicology: extended study, including coverage of less commonly encountered substances
• Prediction of toxicity
• Statistics and epidemiology: for evaluating acute and chronic toxicity of specific substances
• Critical evaluation of literature sources
• Medico-legal aspects
• Research: an appreciation of the methods used in experimental toxicology, toxicovigilance and epidemiology
• Other areas of toxicology: for example, ecotoxicology, occupational toxicology, immunotoxicology, genotoxicity, nanotoxicology, toxinology, forensic toxicology.
TOXICOKINETICS
Trainees in medical toxicology should understand the principles of toxicokinetics and be knowledgeable about the potential effects of absorption by different routes (for example, oral, parenteral, dermal). They should learn basic kinetics modelling and kinetics in overdose and disease states. This section of training should also cover pathways of drug or chemical elimination and modification of absorption (for example, oral activated charcoal) or elimination (for example, haemodialysis, chelation therapy).
TOXIDROMES
Training should cover the toxidromes encountered in poisoning (for example, anticholinergic, cholinergic, opioid, sympathomimetic and sedative–hypnotic), how to recognize a specific toxidrome, the potential drug or chemical causes and how to treat them.
ADVERSE DRUG REACTIONS
While adverse effects after therapeutic use of medications are not strictly poisoning, it is likely that a medical toxicologist will treat patients with such reactions. Therefore, knowledge of the mechanisms of
adverse reactions and assessment of causality should ideally be covered in the curriculum. As some medical toxicologists may be involved in regional or national pharmacovigilance monitoring, knowledge of mechanisms for reporting adverse drug reactions may also be useful.
EPIDEMIOLOGY OF POISONING
The trainee should be familiar with the epidemiology of poisoning, including the prevalence, age- and gender-related risk, geographical variation and any relevant environmental factors. The most commonly occurring toxic substances according to the poisoning pattern in the country or region should be identified, and selected pharmaceuticals, chemicals, chemical products and biological toxins should be the subject of detailed teaching sessions.
MECHANISMS OF TOXICITY OF IMPORTANT AGENTS
Pharmaceuticals: Training should include detailed sessions on antidepressants, antipsychotics, anticonvulsants, antidiabetic drugs, antihistamines, antihypertensives, chloroquine, digoxin, iron, lithium, non-steroidal anti-inflammatory agents, opioids, paracetamol, quinine, salicylates, sedatives and hypnotics, theophylline and warfarin. Other medicines may be added or substituted according to the local epidemiology.
Complementary and alternative medicines: Training should cover Ayurvedic, Chinese and other traditional medicines, homeopathy and herbal medicines., depending on local practices.
Substances of abuse: Training should usually cover stimulants (including amphetamines and related drugs), cannabis, cocaine, y-hydroxybutyrate (GHB), lysergic acid diethylamide (LSD), opioids, new psychoactive substances (such as synthetic cannabinoids, cathinone derivatives), solvents, volatile nitrites and commonly used herbal substances of abuse, depending on the region.
Chemicals: Training should cover chemicals such as acetone, ammonia, toxic alcohols, carbon monoxide, chlorine, corrosives, cyanide, household products, insecticides (for example, organophosphates), rodenticides, herbicides, hydrofluoric acid, hydrogen sulfide and volatile substances. Depending on the risk, training may also include chemical warfare agents (for example, blister and nerve agents) and toxic industrial chemicals. The choice of chemicals to be covered in greater depth will depend on the local epidemiology of poisoning.
Toxic metals and metalloids: Training should cover lead, arsenic, copper, mercury and thallium. Cadmium and chromium may be important in countries where they are used industrially. In regions with heavy industry and occupational exposure to toxic metals, training may also cover environmental and occupational monitoring.
Natural toxins: Natural toxins (particularly from snakes, spiders and scorpions) are a significant public health concern in many regions, and knowledge of local venomous species and current treatment is essential.
Training should cover the local species of snakes and other venomous animals and current guidelines for the treatment of snakebite and stings. Training in poisonous plant and fungal species should also be covered, including both major plant and fungi toxins and commonly occurring local species.
Mixed intoxications: Information is often lacking about this complex area. Understanding interactions and how other agents can increase the effects of poisons and providing advice on clinical management require the best possible clinical and toxicological knowledge.
Radiation: Training may also cover the management of patients exposed to radioactive substances. In some countries, enquiries about radiation may be handled by other specialists.
ELIMINATION AND REDUCED ABSORPTION OF POISONS
The trainee should be taught gastric decontamination methods, including use of activated charcoal, whole bowel irrigation and appropriate use of gastric lavage, on the basis of the latest evidence of the effectiveness
of these measures. The evidence is reviewed periodically as a joint activity by the European Association of Poisons Centres and Clinical Toxicologists and the American Academy of Clinical Toxicology in published position statements.
Trainees should also be familiar with methods for increasing elimination, including extracorporeal methods such as haemodialysis, urinary alkalinization, multiple-dose activated charcoal and endoscopic decontamination. Training should include identification of the substances for which such methods are effective and the indications for their use.
ANTIDOTES
Trainees should understand the general mechanism of action of the antidotes and antivenoms commonly used in the treatment of poisoning. They should understand the indications for use and also avoiding indiscriminate use of antidotes that may not be required, the limitations of their use, dosing and any dosage alteration required because of a patient’s age or underlying medical condition.
KNOWLEDGE AND TREATMENT OF PSYCHIATRIC CONDITIONS
Trainees should be aware of how psychiatric conditions may influence the incidence and type of poisoning.
They should also be aware of any potential implications for treatment of the patient. Trainees should be fully conversant with any legislation regarding consent and treatment of patients who may be regarded as lacking capacity.
10.3.2 OTHER TRAINING ACTIVITIES
Trainees should not only study and gain clinical experience in the management of poisoning but also write a dissertation and participate in teaching activities. Trainees can gain experience in other work in the poison centre and in related disciplines, for example by spending time in:
• a poisons information centre (including training in preparing documents, collecting information, replying to enquiries, recording case data and following up cases);
• a clinical toxicology unit, emergency department or intensive care unit in which poisoned patients are treated (if the poison centre is not already based there); and
• a toxicological laboratory, to gain practical understanding of sampling and analytical methods and of medical interpretation of the results of analyses.
They should also use opportunities to attend or participate in seminars, courses, lectures, conferences, congresses and meetings within and outside the centre and to be active in national and international clinical toxicology associations.
10.3.3 EXAMINATION OR ASSESSMENT
After completion of a medical toxicology training programme, participants should undergo some form of assessment to test their knowledge, skills and approach. The form will depend on the national requirements for certifying specializations.
Competence may be assessed by:
• completion of a logbook or portfolio that demonstrates a minimum level of competence in each training objective;
• peers;
• submission of course work during training; or
• a formal summative assessment, for example, a formal examination.
Once trainees have successfully completed training and passed any required assessment, they may be eligible for accreditation as a medical toxicologist, in countries in which this is a recognized specialty.
10.3.4 CONTINUING PROFESSIONAL DEVELOPMENT
Although the basic professional training of clinical staff is supplemented by experience obtained in their work, the rapid development of toxicology makes continuing education and updating of knowledge a professional and ethical responsibility. The means include reading scientific literature, participating in local, regional and national seminars, meetings and workshops and participating in training courses of several days or weeks. Continued updating of expertise can also be stimulated, for example, by making participation in scientific meetings a condition of certification. In the USA, where professional certification is controlled by boards such as the American Board of Emergency Medicine, evidence of active interest in new developments is necessary to maintain expert status in toxicology. This system not only encourages continuing education but also contributes to career advancement by raising professional status.