Objectives-To determine the level of agreement between senior medical staff when asked to perform retrospective case note review of nursing triage decisions, both before and after development of a consensus approach. Methods-Four medical reviewers independently allocated triage categories to 50 emergency department patients after review oftheir case notes. They were blind to the identity of the triage nurse and their triage categorisation. The process was repeated twice, firstly after agreement on a consensus approach and then using formal guidelines. Results-Agreement between reviewers was initially fair to moderate (ic = 0.27 to 0.53). This failed to improve after development of a consensus approach (K = 0.29 to 0.57). There was a trend towards better agreement when guidelines were used but agreement was still only moderate (I = 0.31 to 0.63).Conclusions-Audit of nurse triage categorisation by senior medical staff performing case note review has only fair to moderate consistency between reviewers. Use ofthis technique will result in frustration among those whose performance is being audited if they recognise inconsistency in the standard they are compared against. (JAccid Emerg Med 1999;16:322-324)

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Nalbuphine hydrochloride is an opioid agonist-antagonist that has gained acceptance as a pre-hospital analgesic agent. Nalbuphine has equal analgesic properties to morphine, has a low addiction potential, and can be stored and administered without restrictions, unlike morphine. To date no clinical evidence has been published to support the theoretical difficulty that the action of opioids administered after nalbuphine could be altered or negated. The foliowing case reports highlight 10 patients who received nalbuphine pre-hospital and subsequently required higher doses of opioid analgesia than expected. The discussion summarises the properties of nalbuphine and identifies potential reasons why excessive amounts of opioid analgesia were required. (7Accid Emerg Med 1999;16:29-31)

One reaction to the medicalization of birth has been the comeback of lay midwives in the past 10 years. While many practice alone as did midwives 80 years ago, now midwives are networking and organizing in regional and statewide groups, an important new distinction in the light of increasing regulatory policy formation by many states. Are these groups the beginnings of traditional bureaucratic health professional organizations or are they better described as alternative women's health groups that espouse nonhierarchical philosophies of women's health? In this article, we describe an empirical study of one such group, the Michigan Midwives' Association, and explore the philosophies and practices of individual members as well as the internal organization of the group and its influence on members. Data were collected using individual telephone interviews with 48 of 50 members, group newsletters and documents, and two spokespersons who developed an oral history of the Association since its origin in 1978. Results suggest that the group plays an important role in reinforcing individually held philosophies about women-controlled birth and in providing social support to health workers practicing outside the traditional system.

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