Objective: To assess the impact of a one-day clinical toxicology workshop in improving knowledge.Methods: A one-day clinical toxicology workshop was conducted as a pre-conference workshop of the Annual Emergency Medicine Conference at the Aga Khan University Hospital, Karachi, in April 2012. The course was composed of poisoning-related common clinical scenarios. The pre-test and post-test understanding was used to assess the impact of the course in improving knowledge. The participants also evaluated the workshop as a whole thorough written evaluation forms. SPSS 19 was ued for statistical analysis of the data.RESULT: There were 22 participants in the course. The pre-test mean score was 31.6 +/- 15.1% (95% CI; 24-40; n = 19) compared to the post-test the mean score of 56.0 +/- 10.8% (95% CI; 47- 61; n = 17). The positive difference was also statistically significant (p \u3c 0.001). The overall workshop was evaluated as excellent by 08 (47.46%) and very good by 10 (52.63%) participants.CONCLUSION: Short training in clinical toxicology improved knowledge of the participants

Fayyaz, Jabeen

Feroze, Asher

Khan, Nadeem Ullah

Khan, Uzma Rahim

English

eCommons@AKU

eCommons@AKUDepartment of Emergency Medicine Medical College, PakistanNovember 2013Importance of clinical toxicology teaching and itsimpact in improving knowledge: sharingexperience from a workshopNadeem Ullah KhanAga Khan University, nadeemullah.khan@aku.eduJabeen FayyazAga Khan UniversityUzma Rahim KhanAga Khan UniversityAsher FerozeAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_emerg_medPart of the Emergency Medicine CommonsRecommended CitationKhan, N. U., Fayyaz, J., Khan, U. R., Feroze, A. (2013). Importance of clinical toxicology teaching and its impact in improvingknowledge: sharing experience from a workshop. Journal of Pakistan Medical Association, 63(11), 1379-1382.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/228IntroductionPoisoning is an important cause of morbidity andmortality.1-3 It has been identified as a significant globalpublic health problem. According to the World HealthOrganisation (WHO) data, an estimated 346,000 people in2004 died worldwide from unintentional poisoning. Ofthese deaths, 91% occurred in low- and middle-incomecountries.4 Poisoning accounts for 0.86-5.9% ofemergency department (ED) visits in developedcountries.5 Pakistan also suffers from poisoning-relatedmortality and a recent study from Rawalpindi reportedsuch deaths to be as high as 7.1%.6Clinical toxicology focuses on the clinical presentationand management of toxic substances and associateddiseases.7,8 Toxicology has now emerged as a sub-specialty of emergency medicine.9 Data has shown thattoxicology-trained physicians provide a cost-effectivemanagement to patients with acute intoxication.10 InPakistan, the initial assessment and clinical managementin the ED of acutely poisoned patients are undertaken byjunior physicians who do not have any formal training inclinical toxicology.11 Even patients are managed byinternists with little training in toxicology. A study hasshown an improvement in clinical care of acutely illpoisoned patients by targeted educationalinterventions.12Formal training in toxicology like fellowship in clinicaltoxicology, is lacking in our undergraduate orpostgraduate curricula. However, the importance ofclinical toxicology has started to get recognition. Thecurrent study was aimed at assessing the impact of a shortone-day course focussing on common scenarios ofclinical toxicology at the ED in improving the knowledgeof the participants. Subjects and MethodsThe study comprised participants of a pre-conferenceworkshop of the Annual Emergency Medicine Conference(AEMC) 2012 held in April at the Aga Khan UniversityHospital. It was a one-day workshop designed to addresspoisoning cases and related case presenting to the EDand other important lethal poisoning of clinicalsignificance. The course participants were Emergencyphysicians, General/Family Medicine practitioners andmedical students.The workshop focus was on the importance of learningclinical toxicology. General principles of poisoningmanagement were thoroughly reviewed. Poisoningscenarios common in the region were discussed. Theclinical impact of environmental and occupationalhazards were also touched upon. A separate sessiondiscussed poisoning issues in children such as "One pillthat can kill" and "common household poison". Mostsessions were scenario-based and the mode of teachingwas problem-based learning. Active participation wassought from the participants and questions andJ Pak Med Assoc1379ORIGINAL ARTICLEImportance of clinical toxicology teaching and its impact in improvingKnowledge: sharing experience from a workshopNadeem Ullah Khan, Jabeen Fayyaz, Uzma Rahim Khan, Asher FerozeAbstractObjective: To assess the impact of a one-day clinical toxicology workshop in improving knowledge. Methods: A one-day clinical toxicology workshop was conducted as a pre-conference workshop of the AnnualEmergency Medicine Conference at the Aga Khan University Hospital, Karachi, in April 2012. The course wascomposed of poisoning-related common clinical scenarios. The pre-test and post-test understanding was used toassess the impact of the course in improving knowledge. The participants also evaluated the workshop as a wholethorough written evaluation forms. SPSS 19 was ued for statistical analysis of the data.Result: There were 22 participants in the course. The pre-test mean score was 31.6±15.1% (95% CI; 24-40; n=19)compared to the post-test the mean score of 56.0±10.8% (95% CI; 47- 61; n=17). The positive difference was alsostatistically significant (p<0.001). The overall workshop was evaluated as excellent by 08 (47.46%) and very good by10 (52.63%) participants.Conclusion: Short training in clinical toxicology improved knowledge of the participants.Keywords: Clinical toxicology, Emergency medicine, Teaching, Pakistan. (JPMA 63: 1379; 2013)Department of Emergency Medicine, Aga Khan University Hospital, Karachi.Correspondence: Jabeen Fayyaz. Email: jabeen.fayyaz@aku.edureasoning were encouraged.Pre-test and post-test quizzes were conducted to find outthe impact of the course on knowledge increase amongthe participants. The pre-test quiz consisted of 20 multiplechoice questions (MCQs), while the post-test quizcomprised 30 MCQs. Both the quizzes comprisedquestions from standard text book e.g. "Tintinalli'sEmergency Medicine; A Comprehensive Study Guide" and"Gold Frank's Toxicologic Emergencies".13,14 The questionswere of, scenario-based "Choose the best answer", formatand covered several topics (Table-1), and all were MCQs(Table-2). There was no negative marking.At the end of the course, evaluation forms were circulatedto get feedback related to the entire workshopexperience. The participants were asked about objectivesof the activity defined; content covered as per definedobjective; overall presentation matching the participant'sVol. 63, No. 11, November 2013Importance of clinical toxicology teaching and its impact in improving Knowledge: sharing experiencefrom aworkshop 1380Table-1: Course content of Clinical Toxicology workshop.Introduction to Toxicological EmergenciesGeneral principles of management of poisoningCase discussion:1. Aspirin Toxicity2. Paracetamol poisoningCase discussion3. Gaseous poisoningOne Pill that can killToxic EnvenomationPesticide poisoningCase discussion4. Household toxinsHydrocarbonsAlcohol poisoningCase discussion5. Heavy metal poisoningTable-2: Sample of pre-test and post-test questions.S.No Multiple choice Question1. A young man is brought to ED by the custom agent with the suspicion of gastrointestinal drug smuggling. He has normal vital signs and normal examination. Which of thefollowing is the appropriate management:a. Immediate surgical removalb. Keeping the patient in ICU for observationc. Oral bulk laxatives therapy in ICUd. Oral activated charcoal and whole bowel irrigatione. Single dose activated charcoal without a cathartic2. A 30 year old man is brought to ED comatosed. His pupils are small and breathing rate is very slow. There is secretions in the upper airway. The best immediate antidoterecommended in this patient is:f. Atropineg. Flumezanilh. Nalaxonei. Glucosej. Thiamine3. Which of the following is true of acetaminophen toxicity in pregnancy?k.  N- acetyl cysteine does not cross the human placental.  The foetus is of incapable of producing NAPQI until late in the third trimesterm. The Rumack Mathew normogram is not applicable to pregnant patients with acute ingestionn. Acetaminophen does not cross the human placentao. In nearly all cases, both foetal and maternal outcome is good if N- acetyl cysteine is used in a timely manner4. A 3 year old child accidentally ingested unknown number of ferrous sulphate tab 300mg two hours ago. The child presented with vomiting and loose stool. On examination childis lethargic with a pulse 120/min BP 100/60 temp 37°C and RR 20min. There is tenderness in epigastrium otherwise rest of the examination is unremarkable. His serum Ironlevel 4hr after presenting to ED is 500 microgram/dL. Normal serum iron level of a three year old child is 50-120 microgram /dL.The proven therapy in this case includea) Activated charcoalb) Gastric lavagec) Deferoxamined) Haemodialysise) Symptomatic treatment only*Reference1. Gold Frank's Toxicological Emergencies 9th edition, 20112. Tintinalli's Emergency Medicine (A comprehensive study guide)7th edition, 2011ED: Emergency Department. ICU: Intensive Care Unit. NAPQ1: N-aeetyl-p-benzoquinoue imine.level of understanding; level of interaction; acquired newknowledge; time management; queries responded;organisation of the activity; quality of course material, ifprovided; overall assessment of the activity.The rating of the activity was assessed on a five-pointscale; excellent scored as 5, very good as 4, good as 3,average as 2; and poor as 1.To calculate mean differences for paired observations inpre- and post-assessment scores, paired t-test was used.Confidence interval for mean scores was also calculatedusing t-statistics. SPSS version 19 was used to analyse thedata.ResultsOf the total 22 participants pre-test and post-test quizzeswere undertaken by 16 (73%), while the overall evaluationform was filled by 19 (86%). The mean score in the pre-testquiz was 31.6±15.1% (95% CI; 24-40; n=19), while in thepost-test quiz the mean score was 56.0±10.8% (95% CI;47- 61; n=17) (Table-3). The difference was positive andstatistically significant (p<0.001) (Figure).The evaluation of the overall course was rated as'excellent' by 8(47.46%), 'very good' by 10 (52.63%) and'good' by 1(5.26%) of the participants. No one rated thecourse as 'average' or 'bad' (Table-4).DiscussionTo the best of our knowledge, it is the first study of its kindfrom the country. It highlights two important facts; first, alack of knowledge among healthcare providers withregards to clinical toxicology evident from suboptimalscores in the pre-test quiz and second, that training inclinical toxicology helps in acquiring knowledge.Participants of the workshop included Family andEmergency physicians, who are likely to encounter casesof clinical toxicology, and the medical students, who wereundergoing clinical training and should have generalknowledge of the management of such cases. Poisoningkills people in the younger age group and the poisoningmortality is high in developing countries overall,including Pakistan.1,15-20While there are various factors forthis high mortality, but we assume that lack of knowledgeof poisoning management could also potentiallycontribute.21 The reason for this lack of knowledge islimited exposure as well as opportunity duringundergraduate and postgraduate training in Pakistan. Asurvey of academic leaders in medical college identified aperceived need of training in Emergency Medicine whichwill help develop the area of clinical toxicology.11In the US, toxicology training is included in the curriculumof Emergency Medicine residency programme.22,23 Theyalso have well-established poison control centres whichoffer training to both undergraduates and postgraduates,in addition to providing awareness and education tocommunity.22,24 Some centres offer hazardous material(HazMat) life support course that are generally 2-3 days inJ Pak Med Assoc1381 N. U. Khan, J. Fayyaz, U. R. Khan, et al.Table-3: Comparison of results.N Mean Score (%) Std.Deviation Minimum Maximum P-Value *Pre-test 16 31.6 15.1 5.0 60.0 <0.001Post-test 16 56.0 10.8 23.3 76.7*Used paired t test.Table-4: Evaluation of overall course.Rating No of candidates Percentage %5 - Excellent 08 47.364- very good 10 52.633- good 01 5.262- Average 0 001- Poor 0 00Total 19 100Figure: Mean scores and Confidence Interval for pre-test and post-test quiz.duration and over toxicological emergencies, includingchemical disaster.25 Toxicology training is also offered as afellowship programme in the US and Master's programmein the UK.26,27 In Pakistan, there are no programmesespecially designed for clinical toxicology training.Forensic Medicine as a curriculum in medical college doescover the medico-legal aspect of toxicology duringundergraduate training, but clinical exposure is limited. InPakistan there are two poison control centres, buteducational opportunities available at these centres arelimited.28The results highlight that even a short training courseimproves knowledge significantly in this subject.29 Thiswill potentially help in improving patient care. The coursewas rated highly and was appreciated by the participants.Some participants commented that this should be offeredover a longer period of time.Including clinical toxicology in the undergraduatecurriculum as well as fellowship in clinical toxicology areneeded and a pre-requisite for reducing the injury burdenrelated to this preventable cause. ConclusionClinical toxicology knowledge is lacking amonghealthcare providers. Short training course helps inimproving the knowledge significantly.AcknowledgementWe are grateful to Asher Bin Feroze for statisticalassistance.References 1. Juntti-Patinen L, Kuitunen T, Pere P, Neuvonen PJ. Drug-relatedvisits to a district hospital emergency room. Basic Clin PharmacolToxicol 2006; 98: 212-7.2. Raschetti R, Morgutti M, Menniti-Ippolito F, Belisari A, Rossignoli A,Longhini P, et al. Suspected adverse drug events requiringemergency department visits or hospital admissions. Eur J ClinPharmacol 1999; 54: 959-63.3. Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, SchroederTJ, Annest JL. National surveillance of emergency department visitsfor outpatient adverse drug events. JAMA 2006; 296: 1858-66.4. World Health Organization. Poisoning Prevention andManagement, 2004.5. Stoukides CA, D'Agostino PR, Kaufman MB. Adverse drugreaction surveillance in an emergency room. Am J Hosp Pharm1993; 50: 712-4. 6. Khurram M, Mahmood N, Ikram N. Unintentional poisoning:experience at a medical unit. J Rawal Med Coll 2010; 14: 46-8.7. Gossel TA, Bricker DJ. Basic principles of toxicology. In: Gossel TA,Bricker DJ (eds.). Principles of Clinical Toxicology. New York, NY:Raven Press; 2002.8. Katzung BG, Masters SB, Trevor AJ (eds.). Basic and ClinicalPharmacology. 11th ed. New York, NY: McGraw-Hill; 2009.9. Munger BS, Whelan GP. Role of the American Board of EmergencyMedicine in the specialty of emergency medicine. Ann EmergMed 1997; 30: 219-23.10. Chung AHY, Tsui SH, Tong HK. The impact of an emergencydepartment toxicology team in the management of acuteintoxication. Hong Kong J Emerg Med 2007; 14: 134-43.11. Razzak JA, Ahmed A, Saleem AF, Nasrullah M. Perceived need foremergency medicine training in Pakistan: a survey of medicaleducation leadership. Emerg Med Australas 2009; 21: 143-6.12. Greene SL, Wood DM, Gawarammana IB, Warren-Gash C, Drake N,Jones AL, et al. Improvement in the management of acutely poisonedpatients using an electronic database, prospective audit and targetededucational intervention. Postgrad Med J 2008; 84: 603-8.13. Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka Rk, MecklerGD (eds.). Tintinalli's Emergency Medicine: A ComprehensiveStudy Guide. 7th ed. New York, NY: McGraw-Hill Medical; 2010.14. Flomenbaum N, Goldfrank LR, Hoffman RS, Howland MA, LewinNA, Nelson LS (eds.). Goldfrank's Toxicologic Emergencies. 8th ed.New York: McGraw-Hill Professional; 2006.15. Tufekci IB, Curgunlu A, Sirin F. Characteristics of acute adultpoisoning cases admitted to a university hospital in Istanbul. HumExp Toxicol 2004; 23: 347-51.16. Murali R, Bhalla A, Singh D, Singh S. Acute pesticide poisoning: 15years experience of a large North-West Indian hospital. ClinToxicol 2009; 47: 35-8.17. Shahid M, Hyder AA. Deliberate self-harm and suicide: a reviewfrom Pakistan. Int J Inj Contr Saf Promot 2008; 15: 233-41.18. Iff, II. HEALTH HAZARDS OF PESTICIDES IN PAKISTAN. 2000.19. Memon Y, Majeed R, Kolachi HBUX, Querashi K, Sheikh S. Clinicalspectrum and outcome of accidental poisoning in children.Biomedica 2010; 26: 92-5.20. Manzar N, Saad SM, Manzar B, Fatima SS. The study of etiologicaland demographic characteristics of acute household accidentalpoisoning in children-a consecutive case series study fromPakistan. BMC Pediatr 2010; 10:28. doi: 10.1186/1471-2431-10-28.21. Siddiqui EU, Razzak JA, Naz F, Khan SJ. Factors associated withhydrocarbon ingestion in children. J Pak Med Assoc 2008; 58: 608-12.22. Dart RC (ed). Medical Toxicology. Philadelphia, PA: LippincottWilliams & Wilkins; 2004.23. Arnold JL. International emergency medicine and the recentdevelopment of emergency medicine worldwide. Ann EmergMed 1999; 33: 97-103.24. Burdick WP, Jouriles NJ, D'Onofrio G, Kass LE, Mahoney JF, RestifoKM. Emergency medicine in undergraduate education.AcadEmerg Med 1998; 5: 1105-10.25. Moye PK, Pesik N, Terndrup T, Roe J, Weissman N, Houston TK, et al.Bioterrorism training in US emergency medicine residencies: hasit changed since 9/11? Acad Emerg Med 2007; 14: 221-7.26. Thomas SHL. An agenda for UK clinical pharmacology: developingand delivering clinical toxicology in the UK National HealthService. Br J Clin Pharmacol 2012; 73: 878-83.27. Tormey WP, Moore T. Poisonings and clinical toxicology: atemplate for Ireland. Ir J Med Sci 2013; 182: 17-23.doi:10.1007/s11845-012-0828-3.28. Turabi A, Hasan S, Ara J, Ahmed M. Drug overdose; studyconducted at National Poison Control Center. Pak J Pharmacol2006; 23: 31-7.29. Alsharif NZ. A standardized patient-oriented approach toteaching clinical toxicology. Am J Pharm Educ 2008; 72: 120.Vol. 63, No. 11, November 2013Importance of clinical toxicology teaching and its impact in improving Knowledge: sharing experiencefrom aworkshop 1382

Importance of clinical toxicology teaching and its impact in improving knowledge: sharing experience from a workshop

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Importance of clinical toxicology teaching and its impact in improving knowledge: sharing experience from a workshop

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