Oh, I agree, absolutely. I trained as a corpsman during the Vietnam era and have always made my own clinical decisions based on experience and gut instinct, most of which I developed then--not in nursing school later. I have to say it drives me crazy when I work in an OR where even experienced RNs cannot make the simplest clinical decisions without running for the Policies and Procedures Manual, not recognizing that every case is different; that not all patient care can or should be delivered "by the book--"
I am more concerned about the times JCAHO comes around, asking for written drug administration protocols, or if a legal case was to come up, i.e. involving intraop quadraplegia during a risky spinal case in which there is a high chance of paralysis post-op anyway, despite sophisticated neuro monitoring--or when there are brand new RNs in the OR orienting, and they don't have the experience to make complicated clinical judgements without guidelines--
I always tell new nurses that I am orienting that guidelines are just that--GUIDELINES--not hard and fast rules written in stone. However, in a paralysis case, you can bet that attorneys are going to be asking for written standards of care, despite the fact that informed consent cites paralysis, even death, as a possible complication of spinal surgery, especially ones with pre-existing severe stenosis or cord compression issues.
I don't see anything in the extensive research I have done that recommends the use of Solu-Medrol pre-op; only for the treatment of spinal shock once a
an insult to the spine has occurred, and then within that critical time frame. This is my point--I still see it being given routinely pre-op by neurosurgeons who believe it helps, and by anesthesia providers who apparently do, as well. I am an OR nurse, not a CRNA. I am concerned about my own liability whether I not I give the Solu-Medrol to the CRNA or anesthesiologist, since there seem to be different schools of thought on pre-op steroids, depending where the neurosurgeon or anesthesia provider trained, or how long they have been working, and what has worked for them in the past.
That is why I brought up the issue of pre-op Decadron to minimize laryngeal edema. I have worked with anesthesiologists and ENT docs who swear by it, and have written papers on it. I have also worked with anesthesiologists and ENT docs who swear that it makes no difference whatsoever, and don't give it. Who ya gonna believe? What happens in court if a patient, particularly a child, DOES have a bad outcome (i.e, cerebral anoxia or even death from airway edema) and the plaintiff lawyers have the research that indicates it DOES work? And what happens when they ask us, as RNs circulating in the room "In your experience, have you worked with anesthesia providers and ENT doctors who routinely give Decadron to minimize laryngeal edema? Are you familiar with the literature that supports its use? As a matter of fact, didn't Doctor X, where you used to work, write one of the articles recommending its use in pediatric ENT cases? Then why didn't you, as the circulating nurse and patient's advocate, ensure that it was given to this pediatric patient?" As RNs, we do our own reading,research, CE classes, and have our own stories to tell about how we did it in other operating rooms and why, but we don't make the final decisions, despite our levels of knowledge, skill and clinical experience. I think we are in a really vulnerable position.