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Amanda Ruback
Community Outreach Coordinator, Missouri Poison Center
Introduced to public health while providing health education overseas
I always knew I wanted to become a nurse. What pushed me into public health is some health education I have done in Mexico, Kenya, and Madagascar where I helped teach how to wash your hands, clean dishes, medication usage, and ways to keep your family safe. When I first started these trips, it was like you do some good work, leave, and people go back to their lives. I didn’t understand the concepts of privilege, social inequality, and bias in healthcare. More recently, we moved away from standard missions to more of a train-the-trainer approach, actually bringing in local physicians, pharmacists, and medical providers who then continue the process of giving medical treatment and education. Groups continue to go back year after year to keep that up. So that was kind of my jump into public health, teaching others how to do tasks that we sometimes take for granted. And through that, I developed this desire to work in the community through health education.
Similarities in barriers to health overseas and in Missouri
No matter if you’re from a rural or an urban area, or an impoverished or a wealthy area, we all have medical needs. During my medical travels, the main issue we were seeing was a lack of access. The ratio of medical staff to community residents was low, and people didn’t always have transportation to get to medical care.
That same issue exists for our community. Certainly, in parts of rural Missouri, we’re seeing that with hospitals closing. In some counties, the nearest physician is miles and miles away. There are obviously other issues too, like healthcare inadequacies, ability to pay, or finding a practitioner who looks like you or believes in what you believe. These are all human issues, as opposed to issues based on where you are in the world.
Background as a nurse and in public health
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Working at the Missouri Poison Center for the last 12 years is really the first public health career I’ve had. I was working in a hospital as a staff nurse and in a doctor’s office for a short time fresh out of nursing school. Now I teach about how to keep your home poison-safe and how to keep your kids and you safe from poisons, too. We take calls from the entire state of Missouri. First, I worked on the hotline answering calls from the public and responding to parents and hospitals and all sorts of people who needed poison related information. Then I started my
current role as Community Outreach Coordinator, meaning I teach anybody who will listen about poison prevention from mom groups and scout troops to health fairs, hospitals, and health departments.
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Public health’s role is to bridge those gaps in access to care and affordability, to be the face in the community, to be that organization that residents can come to. At the Missouri Poison Center, anybody in Missouri can call in. It’s a free service. You can speak to a registered nurse or a pharmacist within a few minutes. We have a language line and all sorts of built-in capacities to hopefully make information easy to access. That’s what public health, in general, should be — a connector to different resources to make our community better, whether it’s physical health or mental health or other sorts of issues.
We rely on state and federal funding among other sources, so it’s important to consider that the money put into these programs does improve the system. We’ve learned that — and it’s been quite a few years since this research was done — but, every dollar that goes into Missouri Poison Center saves $13 in unnecessary health care spending because we keep people out of the emergency room who don’t need to be there. Now, with COVID, we especially don’t want to be sending them to hospitals. So it’s important to be funded as well as be recognized for all the incredibly hard work that a lot of these organizations are doing right now in addition to traditional hospitals and clinics
Funding for mental health
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Mental health is not being funded in the way we need it to be. Even before COVID, there were sometimes month-long waits to get into a mental health provider. We certainly see that with people who may use the Poison Help Line as somewhere they can reach out to as well. Some call just to talk or share what they’re concerned about or, unfortunately, what medications they might consider using or misusing.
We manage both intentional ingestions as well as unintentional accidents or mistakes for all ages. And one thing we’ve noticed is that the rate of tween and preteen self-harm with medicine is increasing. The numbers nearly doubled among ages 10 to 15 in the year 2020, as compared to 2019 and 2018. We provide medical assistance and treatment recommendations, but we’re not trained to offer in-depth psychological assistance. And we have to consider that somebody may need a person to talk to. So we share resources for the suicide hotline and have started doing a lot of social media messaging on harm reduction.
We also educate people about keeping medicine locked up, no matter the age of your kids. It’s not just for the safety of kids under five why you should keep medicine locked up, it’s for your teenagers and adult visitors and people who may have access to things they shouldn’t, too.
What the Missouri Poison Center offers
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We’re a telephone triage line for poisonings. We have 25 or so nurses and pharmacists, as well as physicians who oversee everything. If someone has questions about a medicine or they took too much or they want to know what to do for a poisoning, they can call us. We’re basically answering questions for people like, ‘What do I do now and what do I need to be worried about?’ We do calculations based on weight and look at people’s history, then figure out what happened and what we need to do. If they need to go to the hospital, especially if it’s self-harm-related, we would call ahead, make sure they know where to go, then give the hospital the information via phone and fax.
We also talk to nurses, doctors, and pharmacists to provide treatment advice for each substance. The information is especially helpful in rural areas where a person may have ingested a substance or medication that providers don’t come across often or aren’t as familiar with as some of the larger hospitals in the city would be. We also make sure we follow up through the entire process and check back in to see the outcome.
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We are the poison center for the entire state, so managing poison exposures is definitely something we specialize in. Beyond the nursing or pharmacist degrees our staff have, we all sit for a board exam called a Certified Specialist in Poison Information (CSPI). It takes about one to two years to train for. So we’re more than just operators or call takers. In terms of charting and managing everything, we rely on a lot of technology. We have a ginormous database with information on a variety of medicines, cleaners, and other poisons, and it gives us ingredients, dosing, and treatment guidance. We also have to rely on communication with each other, so there’s a lot of checking in to make sure we’re covering our bases. Through a combination of technology and training, that gives us the ability to do what we do.
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Her poison control experience in both urban and rural areas
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I grew up in a rural farming community of 800 people in Wisconsin. I lived there through college and then married my husband who took a job in St. Louis. So I needed to adapt to an urban lifestyle very quickly. But I actually did research on rural versus urban differences in poisoning for our annual toxicology conference, and it’s kind of my passion project. I first looked at Missouri’s geographic areas and differentiated them between urban and rural areas. Then I looked at all the top substances and where they were called in from. Each time a call is made,
we get a zip code. So we can do monitoring and surveillance to make sure there’s no outbreak of something or when something is new to the market. Then I looked at what the most common calls came in for in rural and urban areas and categorized them. The result wasn’t super alarming or surprising, but it did show the differences in where people live and what they’re exposed to.
In terms of poisoning, kids under five are definitely the biggest culprits in rural and urban areas because they get into cleaners, hand sanitizer, and medicine. Then we also see drug misuse with heroin, fentanyl, and meth across the state. In urban areas, we see more air quality issues. But rural areas definitely have bigger differences. We see more farming-related pesticides as well as veterinary products, herbicides, and other outdoor poisons. We also hear of snake and spider bites as well as plant and mushroom exposures, and help manage those as well.
Her perception of public health while growing up
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I can’t say I had a lot of knowledge about public health growing up. I knew that someone was keeping our food and water sources safe and giving immunizations, but I didn’t really understand their role. I just remember going to the one doctor in town and he was the guy that kind of did everything. That’s probably still fairly true for some rural communities today.
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In rural areas, people really stick together. You may know your doctor and you can call them at a moment’s notice to get in quickly. Often, that’s the first way to get assistance. But also, you had to be really sick to go to the hospital. You might rely on self-treatment just because otherwise, it’s an expense or long journey to receive treatment.
Public health role in community wellbeing
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In general, health departments play a great role in their community, and I’m seeing that more and more during COVID. They’ve stepped up with doing vaccinations on top of the work they’ve always done, like making sure restaurants are inspected. Still, one way we could improve is to become more aware of other organizations in the state that run safety programs or connect people with resources.
Even though we do different things, a lot of us in the public health realm can help each other out. I work in poison control, but I have great contacts for people who need a safe place for their baby to sleep or to find help with lead testing. We need to continue to support each other, promote our resources, and collaborate.
Her own poison scare when her son bit into a glow stick
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I was a nurse on the Poison Help Line, and my oldest kid was probably seven at the time. I wasn’t working that night, but I turned the corner and saw his mouth glowing. He bit into a glow stick. The room was dark because we were watching TV and his whole mouth, the couch, and the floor were glowing. I knew as a poison nurse that it’s not a big deal because it’s a pretty low-risk item. But for a moment, your mom panic acts up and your training goes out the window. You know how to respond, but you’re still human. And it’s like, "Oh my goodness, what
do I do?" But then your training kicks in: "Okay, let’s be calm. Let’s work this through."
We’re experts. This is a type of call we get almost every day, especially on Halloween and on the 4th of July. It’s always nice to reassure parents because many times, especially moms, they give themselves a hard time. They feel doubt and shame when something happens and they’re worried that if they call, we’re going to forward them to child protective services, which we don’t do at all. So I always tried to say, "Hey, here’s the story of what happened to me," just to have that relatable scenario to make them feel comfortable.
Missouri Poison Center's changing role during the COVID pandemic
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Early on during COVID, we had an increase in calls to the poison center. Specifically, there were three types: hand sanitizer, bleach, and disinfectants. All of these things we were using to keep our homes and ourselves safe. Also, the self-harm types of calls went up and there’s a lot of concern with that especially because of isolation issues. Because we are one of the state’s only 24-hour staffed nurse and pharmacist lines, we actually took on the COVID hotline for about four weeks when it started up in March 2020. So we worked directly with the Missouri Department of Health and Senior Services to staff two lines: our primary Poison Center line and the COVID helpline.
People would call and ask, "Where’s the closest health center? What are symptoms of COVID? Where can I get treatment?" So we ran both lines for quite a few weeks until the capacity was built up for the state to take over. That was a hard time. Anybody who did not work on the hotline — myself, our director, our physician — all got pulled to assist during this time. We hired a bunch of furloughed nurses from our host institution. We hired pharmacy students from the local pharmacy school.
Even though we were not hands-on managing all the physical things that hospital nurses were, we remained an important resource. There was a lot of panic and fear in the community, especially early on. People wanted to know what to do while we were still trying to figure out what to do ourselves. We would have to update our responses to different questions in our databases hourly. So it was a challenging time, but definitely something that was needed and that we are proud of.
Amanda Ruback, MSN, RN, CSPI
Community Outreach Coordinator
Missouri Poison Center
Storytelling and photos by: