By David Satterlee
The miserable old man lay in his hospital bed, staring at the clock on the wall. The nurse had just left after waking him from a vivid dream to take a sample of his blood. They were probably checking to see if he still had elevated amylase and lipase in his blood; indicating pancreatitis. “Hell,” he mused, his stomach was still distended; anyone could see that. “Hell,” he mused, “if the disease doesn’t kill me, all this bloodletting will.”
He hated that dream. It haunted him from before he retired; before his wife had died; before he started drinking. Always, he was railing against an illogical way of doing things at the gasoline refinery where he used to work. Sometimes he was complaining to other engineers; occasionally to supervisors, managers, or even the working stiffs whose only concern was to follow orders. Always, nobody seemed to think that his issues were important enough to worry about, to say nothing of making the major changes for which he lobbied. It was the way that things had been done for years. It had become codified into operational software and work habits. Nobody seemed to care—nobody had ever cared except that noble champion of what was right and true that he used to be; this impotent, disillusioned, and very desolate old man that he was now.
In his dream, the engineer, still an earnest, idealistic, and fastidiously through young man, is speaking: “I have reviewed our new plant-wide data acquisition and reporting system. It has several design flaws, related to time, that need to be corrected. The first issue has to do with sample times for analytical laboratory tests. The system is designed to record real-time measurements of continuous process temperature, flow, pressure, and level at intervals down to one second. One of the benefits used to justify our new data acquisition system is the ability to incorporate laboratory test results, such as boiling point or viscosity, into the same displays and reports as the continuously metered measurements. The problem is that our laboratory preprints labels to be placed on sample bottles and these labels only show the time that the sample is scheduled to be picked up at the unit by the lab’s collection truck. It would be nice if we recorded the time that the lab test was completed, but that is a minor issue. The major issue is that the only thing that ties the sample test results to our continuous process measurements is the actual time that the sample was removed from the process stream! And… there is no provision for recording the actual sample time. When we look at the ‘sample time’ on a report, we are actually seeing the scheduled sample pick-up time. It gets worse. Because all samples are due at the same time, unit operators begin drawing these samples early, sometimes hours ahead of pick-up, at arbitrary and variable times according to their individual convenience. I was shocked to discover another distressing issue. For whatever reasons, some units keep reserves of previously-extracted process samples, which they send to the lab instead of new samples. Do you remember the fire that shut down our catalytic hydrocracker last week? The reports showed that two hours after the upset, while all the vessels were still being dumped to flare, several product streams, although having zero flow, were still on spec.
“Secondly, we are corrupting our data every time we shift to or from Daylight Savings Time. The policy is to simply reset the system clock. The result is that every spring, the units appear to disappear for an hour, before reappearing out of nowhere, and every fall, every instruments’ measurements for one hour are intermixed with their history for the previous hour. Both events make hourly and daily averages inaccurate. We are responsible to OSHA and the EPA to maintain accurate records that can be used to reconstruct and analyze exception events. Especially in the fall, we are systematically making that impossible. Unfortunately, the only solution I can think of is to operate refinery processes on Standard Time even when everything switches to Daylight Savings.” And so it went, in one version or another, to one person or another; the argument sound, the effort futile.
The nurse had interrupted that dream. He would have been grateful for that interruption, but for the irony, as we shall see. It had happened in this way: “Time for a blood draw Mr. Dawson.” Glancing at the wall clock, he challenged her, “It’s only 5:06 in the morning. I thought Doctor Wallent had charted it for 7:00 o’clock.” Nurse Betty looked annoyed. “It’s okay, it won’t make any difference. I’ve got a lot to do before going off-shift so I’m getting some of my work done early. And besides, I’ve actually got four patients with blood draws scheduled for seven o’clock; I can’t do all of them at the same time, can I?” This seemed to settle the issue.
Being a well-trained professional phlebotomist, Nurse Betty did an efficient and commendable job of extracting her sample from Mr. Dawson’s right-side median cubital vein on her first try, and with a minimum of discomfort to the patient. Nurse Betty put a pre-printed label on the sample tube and started packing to leave. Mr. Dawson scowled with annoyance. “Aren’t you going to write down the actual time that you took my blood sample?”
Nurse Betty scowled with annoyance. “It’s preprinted. They don’t give me a place to enter that information. Like I said, it’s not a problem; don’t worry about it.” She didn’t realize that Mr. Dawson had been worrying about precisely this for several decades. Nurse Betty had the grace to turn down the lights when she left at 5:13.
Mr. Dawson, realized that the universe had just shown him, as clearly as two billboards in a row with bright flashing lights, that now was the time to finally do something definitive about his frustration. He poured himself a glass of tepid water. He fastidiously wiped up the ring of moisture left by a little remaining condensation on the outside of his plastic pitcher. Fishing in the drawer of his bedside table, he removed all the tablets of narcotic painkiller that he had been palming. He took them methodically; each swallowed with a sip of water. He finished at 5:18, coded at 5:56, and was pronounced dead at about 6 o’clock or somewhere thereabouts. Mr. Dawson’s corpse was logged into the basement morgue at 6:42. Nobody ever noticed or cared that a laboratory report showed that his blood, supposedly drawn 18 minutes later at 7:00 am, contained elevated enzyme levels.
The author’s actual recurring dream. It’s Monday, December 20, 2010. I woke up at 5:06 am with the same damn dream and couldn’t go back to sleep. Here is the crux of the matter: it was a real issue. And, I still can’t do anything about it but whine to another audience.
Copyright 2010 David Satterlee
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