Perhaps the hardest

One of the hardest decisions I have ever made in my medical career was to agree to an abdominal hysterectomy in a mentally challenged lady.

I trained in two unconnected fields of medicine after I completed my Undergraduate Medical studies. I trained in ObGyn and Dermatology. When we went to the Himalayas in the early 70s, I needed training in Obs/Gyn. Both the Gida Kom Hospital in Bhutan and the Anandaban Hospital in Nepal were run by the Leprosy Mission International. They were stand alone hospitals for hills around and the hospitals took care of the general health of the surrounding villages. ObGyn training would hold me in good stead.

Ob/Gyn was not a speciality of my choice. I loved Obstetrics and delivering babies. I marveled at the miracle of birth every time I delivered a baby, but I did not enjoy Gynaecology when I had to terminate pregnancies and do abortions. I was not comfortable . I was distinctly more uncomfortable when someone who had gone to a “quack”, came back infected after an abortion done under sub-optimal conditions. I wished I had obliged and done the procedure under aseptic conditions and spared prevented sepsis in the patient. . Either way I felt bad.

Years later  I was awarded the Ciba Geigy Scholarship  to train for Dermatology at St  John’s Hospital in London. I was then able to shift gears and practice bread and butter Dermatology sans Cosmetology and leave my ObGyn practice behind .

One of the hardest decisions that I ever made in my medical career was to agree to an elective Abdominal Hysterectomy in a mentally challenged lady when I was working in  our Nursing Home in Chennai. She was the niece of a colleague, a doctor who worked with us in the Nursing Home. His elder sister had just  the one child, a  20 year old mentally challenged girl who was classified as” profound mental retardation.” Both the parents were in the late 70s and struggling with illnesses of their own. They were unable to care for her and they knew that when the time came they would have to depend on relatives to institutionalise her. They knew that after their time she would be vulnerable, especially in an institution.

They came seeking an abdominal hysterectomy so that she would never conceive even if she was abused. They were aware of all the possibilities that could happen after their time. You might wonder why we did not consider a Tubal ligation which would have prevented a pregnancy. But the truth was that she was incapable of even changing a pad during her menstrual periods. The rest of the month she needed help to go to the toilet, for her bath and all her body needs. She was basically unable to look after herself. She had no understanding of her bodily functions. She could not be trained to look after herself .

The doctor brought the parents and the lady to us. We had individual and group counseling sessions with them.  The mother broke down and sobbed when she was counseled alone. She said that if we did not consider their request, there was only option open to them. She would have to get some rat poison, mix it with their dinner and go to bed hoping that none of them would wake up in the morning.  My heart broke to hear the despair in her voice.

To adhere to the guidelines of Hysterectomy on a mentally challenged lady, multiple counseling sessions were held with a Psychiatrist, Clinical Psychologist and with a trained Medical Social Worker. The consensus was that an anticipatory Hysterectomy to prevent an unwanted pregnancy was not an indication. Her inability to handle her menstrual periods was an indication for a hysterectomy in her case.

A written consent was obtained from her parents. She underwent the surgery with no complications. Her postoperative period was uneventful and she was discharged when it was clear that there were no postoperative complications.

The day she left the Nursing Home, I felt a mix of happy and sad emotions. I was happy that she would not have to worry about her menstrual periods anymore. It was one less burden for her and her aging parents. But deep down, I was happy that she would never bear the brunt of an unwanted pregnancy following sexual abuse in the future. In a strange way, I felt happy that she would be protected when and if it happened.

I wondered what would happen to her in the years to come. I wondered what would happen to her after her parents time. Would she even understand the enormity of all that was happening to her.

Now or then.





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