“COMMITMENT IS HALF THE TASK” (Dr. Olive Kobusingye)

By: Annet Alenyo Ngabirano, Joseph Kalanzi, Stone Luggya

If you have written or read any paper – research, commentary etc. on Emergency Trauma Care in Uganda, or other Low Resource Settings, then you have heard of or perhaps know Dr. Olive Kobusingye.

On 21^st January, EMU, had a chat her on what was, what is and a little of what is to come in Emergency Medical Care in Uganda!! We bring you some excerpts from the chat.

Who is Dr. Olive Kobusingye?

Dr. Olive Kobusingye MD, MpH is the Executive Director at Injury Control Center, Kampala. She is an Accident & Emergency Surgeon at Makerere University teaching Hospital (Mulago National Referral Hospital) in Kampala. She has extensive experience in the design and implementation of injury surveillance systems in Low resource settings and is the former Regional Advisor on Violence and Injury prevention, WHO Regional Office for Africa.

EMU: What do you recall about Emergency Medicine in Uganda during your earlier days?

Dr. Olive: When I used to work in A&E in Mulago, there was a sense that it was an important area, but it wasn’t being seen as a system, but rather Individuals working in one place, with no specific training to work in this area. Doctors posted to the Casualty had basic medical training, and even we surgeons were also there.

In Mulago, which is a general reflection of what is in the rest of the country, previously Emergency Ward was just surgical but later, the medical aspect was introduced. Such that A&E became both medical and surgical. But there were also areas like ICU that stood on their own.

Things have moved along since those days, and now people know that you can have people trained to

L-R: Joseph Kalanzi, Olive Kobusingye, Stone Tonny Luggya, Annet Alenyo Ngabirano

only work in this area.

One of my Best Nurses Josephine Nabulime (now Chair of the EMU Disaster committee), was quite inspiring, and worked tirelessly despite the challenges.

In 1998, the Ministry of Health came up with a policy that all Hospitals in the country had to have a Public health department and a Casualty Department. This is now part of the MOH standards, and all hospitals must have an area designated for managing Emergencies. I started visiting hospitals to see if they were adhering to these standards. However, it was clear that many hospitals did not have any guidance on what to do. Some simply had a room, with maybe a trolley or stretcher and nothing else. Some didn't know where are you going to assess the patient, who is going to assess and what happens to the patient after?

They had OPD which catered for every condition. They didn't understand that a patient with say Guinea worm who has had it for many years and probably won’t die from it needs a different type of infrastructure from a patient who just came in with a snake bite or RTC.

We tried to help them articulate what is needed. What kind of system makes this happen? Quality Assurance was helping this along. Some of those standards exist on paper but in reality it is a  different part all together. The infrastructure is one thing and the Human Resource is another.

EMU: Where is Emergency Medicine in Uganda now?

Dr. Olive: So the policy exists, even though it is not clear, it is a good point to start. The problem is going to be the infrastructure and the coordination, how they work together and the need to prioritize them.

If you look at the HSSP, there is lot of strategic information and standards in paper but in reality this does not exist.

It is important for such efforts that you get in touch with all the people and stakeholders interested in Emergency Care.

It is really patchy in terms of what do we have on ground, but there is sufficient backing that can be built on.

EMU: What do you think is the scope of Emergency Care in Uganda?

Dr. Olive: That is not a Ugandan problem, but a global problem. I think no matter the context, one can definitely identify the conditions in their setting that are an immediate threat to life, and organize their system to address these.

Even though it’s a broad scope with ambiguity on its boundaries, that should not hamper your efforts.

In one of my classes in the MPH course, I needed to show students the work in an Injury Emergency surgical setting. To understand triage. I took them to a Casualty setting. They had been previously taught the KIS but when we went to the triage desk, the triage nurse did not know any score, and yet inside her desk flap she had the GCS clearly written! It was embarrassing.

Inside the A&E we found a nurse who showed us some.

Thankfully on our way out, we met an Emergency Nurse I had worked with, and without prompting, she gave us all the information we needed to know.

What does it take? Setting a system, is not only a question of the individual components but rather a matter of leadership understanding where they want to go.

Regarding training, it is important for all cadres in EM to understand what the others do.  So in basic trainings, it is important for all cadres to be included together. In that way you will train teams, for example the trauma teams training is as a team.

The Injury Control Center set up a skills Lab in the medical school for surgical skills training which is a good place to start even for resuscitation training.

EMU: We would like your comments on Research Related to Emergency Care in Uganda. The only existing quality research is linked to you and even when we write our own papers we have to quote yours.

DR. Olive: (Laughs): Which are old!! I keep trying to get student[s] interested in this field.

It depends on what you want, but it is an area that is not difficult to go into.

EMU: That is encouraging as a First statement on Research!!

Dr. Olive: Yes, and I stand by it!! Because you will find a lot of literature to guide you, and you will have no shortage of patients. The environments exist. Many people are hampered by numbers of patients, but here, what do you need? I think it is doable.

EMU: Having done a lot of work on pre-hospital care, any comment on the Uganda National Ambulance Service. What do you hope to see?

Dr. Olive: Yes, I received the documents.

I have spent many hours thinking about this and also spoken to Dr. Mukone. There are many ambulances in existence already, but they are not coordinated and we don’t even have a Dispatch Center.

If you look elsewhere at successful Ambulance services, someone has figured out how to call the ambulance, how to asses who needs an ambulance, how to dispatch the ambulance to the right place, how the ambulance can get the person to a facility that can help them etc…. Even if we don’t talk about the skills on board the ambulance, they still need coordination. A lot of coordination.

The dispatch will need to be coordinated and all Health centers will have to work together so that all existing services are known and dispatch should be smooth. And geographical divisions should not hamper dispatch.

Through coordination, a lot of the existing resources both ambulances and also health facilities can actually be put to good use. 

EMU: What advice would you give “EMU” a group of young enthusiastic leaders determined to change the face of Emergency Care?

L-R Drs. J. Kalanzi, O. Kobusingye, S. Luggya, A. Alenyo

Dr. Olive: A society can be quite influential in doing Quality Assurance of all trainings.

However, while you are still an Association, you can still make credible statements about what infrastructure is needed.

You can also use existing literature and WHO guidance on what kind of Human Resource should exist at what level of Healthcare.

A lot of these things will not happen because the Ministry wants them to happen. It will take individuals like yourselves to push. A lot of things are happening because individuals chose to push for change.

“If you have the commitment, it is half the task”.