Post-it note triage: A little documentation, a big difference

sanna_khawajaIn January this year I spent a fortnight volunteering at the Moria Refugee Camp on the Greek island of Lesbos. At the time Médecins Sans Frontières (MSF) was the primary care provider in the camp and was supported by other charities such as Médicines Du Monde*.

The small, UK based Health Point Project I was working under aimed to support the work of these remarkable organisations by providing simple first aid, sharing information with refugees about accessing healthcare in the camp, and referring any individuals identified during “outreach” walks who required escalated care—either to MSF or straight to the local hospital.

On arrival at the camp, refugees were first required to queue up for registration papers to allow them to try to gain access to sleeping quarters, hot meals, and eventually to make their way on to Athens. After the horror of crossing the Aegean sea in icy conditions and the hell that preceded that, the new arrivals at the camp were desperate to complete this one process without delay—even if they were not in a fit state to do so. Consequently, our first encounter with them was as we walked along the queue to perform a quick assessment.

We faced multiple obstacles in attempting to assess and assist this group of people: there was often a language barrier, limited history, and uncertainty about any follow-up—this was, after all, a diverse and transient population. With limited time and equipment, necessity gave birth to the post-it note triage.

This rudimentary system of documentation involved sticking two post-it notes back to back and allowing one translator and healthcare professional to walk along the queue documenting some key information: date, name, age, spoken language, allergies, pre-existing health conditions, current complaint (if any), and a set of observations.

In the first instance, this allowed for immediate escalation of individuals who needed it, such as those with significantly abnormal observations, including moderate to severe hypothermia. It also allowed us to identify those who we could recommend for fast track registration, such as pregnant women, families with disabled members, and families with newborn babies.

A secondary “walk along” of the queue would allow us to spend a bit more time assessing those that required it. Often these were people we could then follow up once they were registered, for example, to arrange for supplies of regular medication or transport to hospitals for outpatient care.

These notes were often well guarded by the refugees and presented to us on further encounters with patients. They allowed colleagues on other shifts to recognise individuals we had seen and follow up on previous assessments. They also helped those carrying them to communicate in their new surroundings. For example, one kind interpreter spent a few minutes with a new mother making a short vocabulary list to enable her to ask for help, even if it was to source nappies or formula milk for her baby. We later received news of these bright pink and yellow squares of paper being of assistance to healthcare professionals in the camp (even if simply helping select the correct interpreters) and local hospitals (particularly the allergy status).

Months later, I am certain that those pieces of paper have long since disintegrated and I fluctuate between optimism and despair as I wonder about the outcomes for those who carried them. Yet we are advised to reflect on our experiences so that we can carry forward the lessons and sentiments we’ve gathered from them in a way that enhances our practice for all future patients. I gained reams of insights, thoughts, observations, and experiences while working on Lesbos—months later though, I find myself only brave enough to reflect on post-its.

Nonetheless, the part those post-it notes played in the refugee camp has made me more appreciative of the role of documentation. The tedious task of discharge summaries now fills me with gratitude that I can ensure whoever follows up my patient will be furnished with the appropriate facts.

When we were faced with a crowd of weary, traumatised, and possibly unwell people, a simple form of triage kept my team and I from becoming overwhelmed and allowed us to be effective, efficient, and of service. I endeavour to remember this lesson whenever I am struck by a barrage of bleeps, queries, and referrals.

*The situation in Moria is vastly different today: UNHCR and MSF pulled out in March citing a “mass expulsion operation” in which they did not wish to be complicit.

Sanna W Khawaja is a core trainee in acute medicine based in London. Twitter: @SannaWaseem

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.