Quality vs quantity.

It is one of those trite and reflexive attitudes that we should always be improving quality. There is little talk of increasing quantity. In fact, quantity is often derided, "mass produced" being somewhat of a negative term.

Often, quality comes at the expense of quantity. I remember going to a public hospital in India and seeing their largest building, the Institute of Neurology, and being told of their expensive CT scanners. A lucky few got the benefit of these things, whilst thousands died for the lack of the simple things. The money that paid for the high status items could have helped many more people if it was used on the diseases that affect millions. One CT scanner costing 3 million dollars could be used to treat 6 million children with antibiotics for childhood pneumonia, the biggest killer of children in poorer countries. Treatment even by simply trained health workers cuts deaths by 27%. Thus we could see a few pretty CT pictures for $3 million, and probably improve our diagnosis of certain things by a bit, for a few people; or we could save 1.5 million children instead.

Basic treatments should be comprehensively available for all before public spending on higher levels of treatment.

We forget that before the onset of mass-production, only the very rich could afford most of the things we take for granted. It is romantic to think of a agrarian society with cottage crafts and artisans, but those who live in the poor villages of India are closest to this, and they want out! If they can they migrate to the cities. Are they duped? I don't think so. It is arrogant to think they are duped while we are wise. No, they just want what we take for granted.

It is mass production (quantity) that allows us the choices we have, to work with our brains instead of our hands. Machines are our slaves now instead of people. And most of our ancestors were slaves, not kings, as would be our lot in a more "natural" society.

I remember being part of an organisation that ran around preparing and collating reports, planning for strategic continuous quality improvement, months and months of work was done, reports produced, plans for continuous interviewing of clients, staff and stakeholders, with lots of meetings for good measure, for a GP clinic to begin. Finally it started operating. On the first day they saw ONE patient. The same day I saw 40. I suppose they would have seen their one patient in a very quality way though.

Endless rounds of bureaucracy and papers call for more quality and end up being a huge quantity of waffle, people running around trying to measure, monitor, report, consult, implement and review. Imagine what we could do if this workforce of paper shufflers could be liberated to do productive work instead!

Fear as allergy.

The Hygiene Hypothesis is the idea that as we stop being exposed to dirt and germs because of too much cleanliness, we develop more allergies and asthma. Our bodies immune system is primed and ready to defend us against multiple old and new threats, and when they do not come, it overreacts to things that are largely harmless. It is like we have an immune army within us, ready to fight the invader with many weapons, when threats fail to appear, the bored army starts to attack anything at all, whether it be pollens, bits of food, or even parts of the body itself.

Perhaps our anxiety epidemic in the midst of unparalleled safety can be partly explained by this too. Our minds are primed to respond to threats and danger; when they do not arise, we must imagine them.

Cotton-wool kids II

A friend asked me what the risk of death from abductions were compared to being run over by 4 wheel drives. It is very hard to find data on non-family abductions. This article deals well with the issue and is a very good read on it's own, it's about a family who gave up using a car and had to cope with their children going places on their own. I can't find any information on Australia. The rate in the United States for 1999 was roughly 115 non-family abductions for a population of 75 million children. Most were teenagers. (Most fear-mongering statisticians include runaways and family dispute abductions.) In Canada there were only five over 2 years. Given Canada's population is 33 million and Canada is more similar to us than the US we can extrapolate, at worst, a similar rate. The Australian ABS says the rate of death by being run over by a vehicle is 254 people per year. (I can't find the age specific data). Safe road use is much more important to teach our children than "stranger danger."

The availability heuristic is a false way of thinking we all use; we think flying in a plane is more dangerous than driving because we can all recall vivid images of aeroplane accidents even when confronted with the facts that driving is safer. Likewise we think of Madeline McCann when we think of letting our child run down the street. For our childrens sake, we need to think straight.

Cotton-wool kids

An old article, but a goody. I remember as a child being bullied in high school by a group of other kids in my class for months on end. This was in the 80's, when kids still played street cricket and wandered the streets on their own, and I always walked to school by myself, and cycled around the streets on my own. I believe it was due to these sort of independent activities that I had enough resilience to find a way out. Adults couldn't help me, I had to help myself. I challenged the gang to a fair fight, but with only one of them. In the end I could not bring myself to do more than wrestle him, (in front of a big crowd at recess) but because I was big that was enough.

After that, the boy I fought became a friend and I was no longer bullied. I believe that it is a common thing among boys, subconscious and instinctive, that hates a wuss but respects courage.

There is no courage without risk, to eliminate risk is to eliminate courage. What a nightmare it would be to live in such a grey world of safety.

Bicycle helmets may kill more than they save.

Another example of the danger of safety: this article in the Pub Med indexed Health Promotion Journal of Australia discusses one of the central dangers of safety: the effect of protecting from one danger may lead to a worse one. Since compulsory bicycle helmet legislation was introduced, cycling rates especially among kids have plummeted. Getting a helmet on is just another barrier to a young kid who wants to go out. Doesn't really fit with a dragstar hoon or a BMX bandit image. So less kids ride. More kids stay at home playing video games, eating chips and getting fat. More diabetes. More heart attacks, strokes and death. After all, these are the great killers in our society far more than bicycle related head injuries.

I disagree with Curnow's assertion that head injuries are worse with helmets than without, reasonably good evidence shows that it is indeed good to wear a helmet. But we should question and examine the possible wider impact of the compulsory nature of this legislation.

Veronica Campbell killed by "quality"

Veronica Campbell died from heavy bleeding caused by an ectopic pregnancy on December 31^st 2008. She was only 60 kms by road from Goulburn Base Hospital. Her life could have been saved if she was operated on urgently. The facilities and surgeon were there, ready, a mere 60 kms away. A trip one could take in 40 minutes. She waited in Cobram hospital for an ambulance for 2 hours. The ambulance said that they were not equipped to take her, so 90 more precious minutes were wasted waiting for an air ambulance. After 4 hours, she was finally en-route. She died in the air.

I am angry. This is a classic example of how our endless “quality improvement” agenda has gone way too far. Common sense has left us. I have been thinking about this for years. I am starting this blog to rail against the absolute stupidity and lack of common sense and political correctness gone mad that is killing people, and hopefully provide a counterpoint to reflexive, inane, useless and wasteful "quality improvement".

If they just jumped in the car and drove straight to the hospital her life would have been saved. Study after study has shown that it is the time to definitive treatment that is the major factor in survival, from anything from cardiac arrest to major trauma.

Here is a study that shows that survival in major chest trauma may be more than doubled if non-ambulance transport is used immediately. "Stay and play" by paramedics trying to follow all the right "quality" protocols leads to over double the deaths compared to an ordinary person chucking them into a car ("scoop and run") and driving fast to a hospital equipped to perform definitive treatment. Despite being staffed by the best "quality" paramedics dotting all the i's and crossing all the t's, subject to continuous and comprehensive "quality" improvement, always completing their documentation, in certain situations all this "quality" care is worse than useless, this "quality" kills.

In Veronica's case, no doubt the first ambulance paramedics were worried that they were not capable of dealing with a problem en-route. There are always punishments for those who break the rules of "quality", even if the patient lives as a result. There are no punishments for following procedures, even if the patient dies. They called for a more expert team. Sadly, the thing that was needed was an urgent operation in the quickest time possible. No amount of expertise and resuscitation can compensate for a loss of time to definitive treatment.

In this case, well over 3 hours were wasted getting the best possible high tech quality transport. Catching a taxi instead would have saved a life.

Important Note: time to definitive treatment is the important concept here. I am not disparaging ambulance services or paramedics, who do an amazing job despite often running into problems with "quality" policy and procedures and documentation requirements. For example, in most cases of cardiac arrest, definitive treatment involves defibrillation, which is speedily carried out by ambulances.