Training activity information
Details
Select appropriate investigation protocols for patients with a suspected diagnosis of the following conditions:
- High anion gap metabolic acidosis
- Paracetamol overdose
- Drug overdose causing reduced level of consciousness
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
What does success look like?
- Identify what is expected of you in relation to selecting an ‘appropriate diagnostic pathway’ for these urgent toxicology and acid-base scenarios.
- Consider how the learning outcomes apply, specifically in relation to applying the appropriate investigative strategy to clinical situations involving drugs or poisons.
- Discuss with your training officer to gain clarity of what is expected of you in relation to identifying the necessary tests, considering sample types and timing, and understanding the rationale behind the pathway.
What is your prior experience of this activity?
- Think about what you already know about the diagnostic approach to high anion gap metabolic acidosis, paracetamol overdose, or drug overdose causing reduced level of consciousness.
- Consider possible challenges you might face during the activity, such as challenges related to complex clinical information or less familiar drug classes.
- Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if you encounter complex clinical information or need assistance related to less familiar drug classes.
- Acknowledge how you feel about making appropriate diagnostic pathway selections for the diagnoses listed.
What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as linking clinical presentations to appropriate laboratory investigations in the context of toxicology and overdose.
- Identify the specific insights you hope to gain into the rationale behind different diagnostic pathways for these urgent conditions.
What additional considerations do you need to make?
- Consult actions identified following previous experiences of other types of urgent samples or result interpretation.
- Identify important information you need to consider before embarking on the activity, such as reviewing relevant clinical guidelines or laboratory protocols for emergency toxicology requests.
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst applying investigative strategies to clinical situations involving drugs or poisons?
- Are you encountering situations such as:
- Ambiguity in the clinical history provided (e.g., unclear timing of ingestion or multiple potential toxins) complicating the standard pathway selection?
- Results of initial tests (e.g., anion gap components) that conflict with the expected presentation of high anion gap metabolic acidosis or paracetamol overdose?
How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to selecting the diagnostic pathway?
- Consider the steps you are taking in the moment, such as:
- Immediately considering alternative tests or sample types (e.g., specific drug screen panels) due to an unclear history
- Halting the definitive pathway selection to consult the local toxicology guidelines for a complicated paracetamol overdose case
- How are you feeling in that moment? For instance, are you finding it difficult to adapt your strategy based on limited clinical details? Is it affecting your confidence in determining an appropriate approach? Did you feel confident you could still determine an appropriate approach?
What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully considering alternative tests and sample types to navigate the ambiguity yourself? Or are you needing support because the ambiguity of the high anion gap metabolic acidosis requires specialist guidance on differential diagnosis?
- What are you learning as a result of the unexpected development? For example, are you gaining insight into the criticality of sample timing for toxicology screens?
On action
What happened?
- Begin by summarising the key steps you took when selecting the diagnostic pathway for the urgent toxicology/acid-base scenario(s) presented.
- Consider specific events, actions, or interactions which felt important, such as how you systematically linked clinical presentation (e.g., unexplained acidosis) to specific laboratory investigations.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately consulting local guidelines when confronted with a complex case of suspected overdose involving multiple potential toxins or when initial test results conflicted with the expected acidosis presentation.
- How did you feel during this experience, e.g., did you feel confident in your rapid access to protocols or stressed by the complexity of the case?
How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding applying investigative strategies to clinical situations involving drugs or poisons. What strengths did you demonstrate, e.g., rapid access to protocols or systematic approach to pathway selection?
- What skills and/or knowledge gaps were evident, e.g., difficulty interpreting certain clinical details, unfamiliarity with specific tests for unusual drug classes, or complex differentials for high anion gap metabolic acidosis?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in selecting diagnostic pathways for urgent cases, particularly in assessing clinical priority?
- Identify any challenges you experienced, such as incomplete clinical information or time pressure to determine the correct pathway, and how you reacted to this.
What will you take from the experience moving forward?
- Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving efficiency and rigor in pathway selection.
- What will you do differently next time you approach selecting a diagnostic pathway for these conditions, for instance, by proactively reviewing specific guidelines for acidosis investigation or paracetamol overdose management before the next encounter?
- Do you need to practise any aspect of the activity further, such as reviewing guidelines for managing complex toxicology emergencies or key learning outcomes related to applying the appropriate investigative strategy to clinical situations involving drugs or poisons?
Beyond action
Have you revisited the experiences?
- How have your subsequent experiences of managing complex acidosis cases or urgent toxicology requests since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent case required rapid differentiation between causes of metabolic acidosis forced you to re-evaluate the depth of your initial information gathering regarding patient medications during your first attempt at this training activity.
- Considering what you understand about urgent toxicology guidelines, drug pharmacokinetics, and investigative strategy now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your protocol adherence and rapid decision-making framework based on further learning and experiences? For example, how you proactively reviewed and integrated national guidelines for N-acetylcysteine (NAC) administration timing based on serum paracetamol levels into your decision matrix, demonstrating adapted improvements based on further learning.
- Has discussing complex toxicology pathways or the urgency of metabolic acidosis escalation or the impact of delayed pathway selection on patient prognosis with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a patient who suffered renal failure due to delayed identification of a high anion gap toxin refined your understanding of the critical nature of rapid application of investigative strategies during the initial assessment.
How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent toxicology and urgent clinical scenarios, contributed to your overall confidence and ability in rapidly selecting appropriate investigative strategies particularly in preparing for assessments like Case-based Discussions (CBDs) or Direct Observations of Practical Skills (DOPS/OCEs)? For example, how your accumulated ability in prioritising information and applying investigative strategies now enables you to confidently advise clinical teams on necessary laboratory tests for an urgent drug overdose case during a CBD assessment.
- How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to managing urgent biochemical scenarios like acidosis or overdose? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek expert toxicologist consultation immediately when a complex case involves multiple unknown drugs or a toxin not covered by standard protocols, recognising this falls outside routine pathway selection scope.
- Looking holistically at your training journey, how has this initial diagnostic pathway selection experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to applying the appropriate investigative strategy to clinical situations involving drugs or poisons? For example, how this foundational experience has supported your development in reviewing and developing laboratory protocols for managing specific toxicology emergencies in the future.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Analyse drugs, vitamins and trace elements in various biological matrices via quantitative and qualitative assays using automated and manual methodologies. |
| # 2 |
Outcome
Apply the appropriate investigative strategy to clinical situations which may involve drugs or poisons, advising clinical teams on the appropriate course of action. |
| # 4 |
Outcome
Summarise the limitations of comprehensive toxicology screening in clinical practice. |
| # 6 |
Outcome
Illustrate how toxicology results are used in clinical practice and the legal consequences of drug testing in various settings. |