N.A.D.

One of the quick shorthands used to describe patients in written hospital notes in the U.S. is “N.A.D.”—no acute distress. It’s an interesting phrase, ripe with the assumption that we are controlling suffering even as we attempt to defeat disease. There is no scribbling “N.A.D.” on the ID ward charts here, because many—if not most—patients emphatically are in acute distress. They wouldn’t be anywhere near Mulago Hospital if they weren’t. It is true that they do not often complain, but it is not necessarily for lack of suffering. On the ID ward, in particular, where the final toll of AIDS is most clear, many of the patients are so ill that it is as though they are not physically present. More than once, I’ve thought a bed or mattress was empty, when actually the scrap of twisted blanket covered a patient, wasted and shrunken into himself with pain, largely unresponsive.

Each patient is supposed to have an attendant, a mother or daughter or brother or grandmother or friend who generally stays at the hospital, sleeping on a mat next to the bed and attending to the patient’s needs, from providing food and blankets to cleaning and changing bedding, to purchasing medicine from the hospital pharmacy and dispensing this medicine, to deciding whether the family can afford a recommended $3 CBC or $10 X-ray. On questioning, these attendants speak for their patients, who often cannot speak themselves: “she is in pain,” “his fever is better” “she still can not eat,” but the ward is still perfused with a sad, passive and palpable sense of helplessness.

A woman ill with toxoplasmosis died on our very first set of morning rounds, just as we were passing the congestion of beds in the hallway. I didn’t even notice this eddy in the quiet chaos until I moved closer to see what the intern was examining and realized the woman’s eyes were fixed. He did a perfunctory check for a pulse amid a sudden surge of women around the bed crying and wringing their hands. The intern shook his head, pulled the blanket up, murmured something to the family, and moved on, into the next room full of patients. Since then, we’ve come to recognize the distinctive collective cry of the family or attendants when a patient dies, the brief wailing outburst heard across the ward that cuts briefly through bedside teaching sessions or morning rounds.

Pain seems to be fought mainly with liter-size glass bottles of pale green liquid morphine, scattered haphazardly around the room near bedsides, squirted into patient mouths with syringes by attendants. One morning, the intern spent five minutes trying to teach an elderly attendant, a patient’s mother, how to draw up morphine into the syringe. The attendant had both vision and dexterity problems, but if she could not get the hang of it, the patient was unlikely to get any pain relief. Patients without attendants, we were told, may not receive medications at all.