1473. Update: KPI: How long it takes to remove a bladder stone?

TOA PAYOH VETS toapayohvets.com Date:   19 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits KPI - How long it takes me to remove a bladder stone in a poodle  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   19 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Friday, June 14, 2013 1460. Update: KPI - How long it takes to remove one bladder stone from a poodle? Friday June 14, 2013 I share my surgical experience with regards to the removal of a bladder stone from an old poodle and to provide a benchmark to enhance the standard of care by younger vets at Toa Payoh Vets. KPI FOR SURGERY How long it takes to remove one bladder stone from a poodle? Poodle, 10 years, 4.1 kg 38.8 C. Dog was panting but owner said this was normal behaviour of excitement. Urinated blood yesterday, incontinent and now had abdominal distension. Had antibiotics for past 7 days. Blood in urine. Dark red cloudy urine. Dog's abdomen distended on arrival. Anti-spasomodic injection and antibiotics enabled dog to pee and on surgery, bladder was empty but swollen with 8 mm wall (normal bladder is around 3 mm)   2 packets of sutures 3/0 absorbable Polysorb, 3/0 nylon for skin A: Injection of Induction Drugs  2.50 pm B:  Isoflurane gas first given:     2.55 pm C: Isoflurane gas stopped:         3.39 pm D: First skin incision:                3.11 pm E: Completion of skin stitching   3.41 pm E-D = 30 minutes for a vet with 40 years of experience.  E-A = 51 minutes C-B = 44 minutes of isoflurane gas + oxygen used. ANAESTHESIA 1. Domitor + Ketamine 0.1 + 0.11 ml IV in 3 ml of saline 2. Dog intubated 5 minutes after Dom + Ketamine IV. She was intubated a few times but seemed not to be breathing the isoflurane. Barked twice. Eyes blinking. I did not want to waste time to mask and intubate as this is an old dog and every second counts towards her survival rate. I decided to use gas mask which was excellent anaesthesia from 3% maximum for maintenance. SURGERY 1. I palpated the empty bladder with stone. In female dog, I do not catherise unless necessary. 2. I incised where the bladder was located. Spread out the SC fat, linea alba cut and pop out the empty bladder. 3. I turned the bladder backwards, exposing the dorsal part of the apex. 4. Incised 1 cm. Popped out the stone which would be slightly >1 cm across. 5. My assistant flushed bladder with saline. I squeezed out any remaining debris or crystals, known to be struvites. 6. A urinary catheter passed from inside bladder to outside the vulva to dislodge any stones if present in the urethra. 7. I suture the 8-mm thick submucosa first with a layer of inverting sutures, parallel to incision. 8. At one end, I anchored the artery forceps and proceeded to suture a similar continuous inverting suture layer to the other end from bladder serosa and mucosa. "Suturing is similar to Caesarean section uterus," I said to Dr Daniel. I used 3/0 Polysorb sutures and throw 5 knots/tie. 9. "Some vets inject saline into the bladder of the female dog after suturing to see if there is a leak," I said to Dr Daniel. "I don't do it as the closure is tight with two layers." He took a video. 10. Closure of the linea alba (simple interrupted & continuous overlay). 11. Skin - horizontal mattress x 3 with 3/0 nylon. 12. There was some profuse bleeding post -op.  "Probably the bigger artery from the caudal epigastric blood vessel," I said. After bandaging, the bleeding stopped. POST OP The dog vomited twice, yellow gastric juice some 15 minutes after surgery, but seemed OK. "Barking non-stop before surgery," I said to the owner who visited. The dog sprang onto him as if she did not have any major op. Still barking non-stop as at 7.35 pm when I recorded this case. Incredible. The owner is advised to give the S/D diet but the dog did not like it. There are still small stones inside the left kidney and S/D may dissolve them. But the dog would not eat the S/D. "Give 10% mixed with home-cooked food and increase daily," I said. "It is important to avoid kidney stone operation!"   An unusual old dog so active 2 hours post op. Compared to the overweight Jack Russell who is drinking lots of water and depressed, lying down 2 days after 10 small bladder stone removal surgery. He would stand up when the owner came. UPDATE ON SUNDAY JULY 16, 2013 The dog went back on Saturday July 15, 2013, on the 2nd day after surgery as she was fit. The other Jack Russell, on 3 bottles of IV drip was more active and barked on Saturday, much to the joy of the owners. He was drinking and drinking a lot of water of Friday lying on his chest and looking lethargic. He would walk when taken out but preferred to lie down for the last two days.. Updates will be on this webpage: www.sinpets.com/F5/20130615stones_urinary_poodle.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: June 19, 2013 Toa Payoh Vets

1472. REVIEW of my case - Follow up on poodle with bladder & kidney stones

The Jack Russell with 10 bladder stones returned today with swelling and seepage of plasma in his wound. So I warded it as he was too active at home. JRs are very active by nature and so the wound healing is affected by jumping up and down. There is a swelling in the op area and the owner brought the dog back for confinement. We sent the dog home to lower medical costs for the owner and usually they can't do good nursing. The dog would have no nonsense from the owner and will not be confined. Free as a bird and this leads to complications if the owner can't confine him.  

I followed up on the poodle as the dog went home on the 2nd day of surgery, it is best for me to follow up with the owner. The past few days showed large areas of bruise on her inguinal area and he had WhatsApp to my intern who forwarded to me. "Now the bruises have gone to the thighs," the owner said at 6.57 pm today Jun 18, 2013. I asked him to WhatsApp my phone as previously my intern Ms Toh had used her phone to WhatsApp to him.

"My dog is eating more and is much more active today," he said.
I asked him to measure the amount of water drank and the colour of urine. Previously, the urine was discoloured dirty brown during the bladder stone operation.

HISTORY
Toy poodle, F, 9 years

1. May 2, 13 Vet - Dr Daniel Sing.   Haematuria few months. On heat. Stranguria
   URINE TEST May 4, 13
  pH 7, SG 1.025, Protein 3+, Blood 4+, WBC >2250, RBC >2250. Bacteria Occasional, Crystals Nil.
  After reviewing this urine test report as I do for all cases handled by my associate vets every day, I asked Dr Daniel whether he had advised X-ray and he said he did. The owner did not want any X-ray to be done.


I scribbled on the report: 1. UTI  2. Bladder stone - didn't want X-ray. I circled Protein 3+ and wrote "kidney".

2. Jun 6, 13  Vet - myself.  Dog not eating for 2 days. Blood in the urine for 2 days. Dripping urine ie. incontinent since last visit for past 2 weeks. No vomiting.
I reviewed the May 2 case. This was serious as Protein 3+ is not usually found in bladder stone cases. Blood test, urine test and X-ray using air contrast were done.

Female dog urethral catherisation using forefinger to feel for the urethral opening and inserting the catheter (see image).
1. Digital rectal examination. No tumour.
2. Digital vagina/vestibular examination.  A soft tissue mass cranial to the urethra.
3. Urethral catherisation
4. 30 ml of air was pumped into the bladder before X-ray

BLOOD TEST
Significant findings
Calcium 0.49 (1.5-3.6)
Urea 10.5 (4.2-6.3) but creatinine level is normal at 135 (89-177)
Total white cell count 41.7 (6-17)
Neutrophils 92.6%. Absolute is 38.61 (very high).
--- bacteria in blood stream. That is why the dog has fever 39.8C



URINE TEST (urine from catherisation, emptying bladder before air contrast X-tay)
pH 8, SG 1.027, Nitrite +, Protein 3+, Blood 4+, WBC 1125, RBC 15, Bacteria 3+, Crystals Triple phosphate +


X RAY 
Left kidney stones, bladder stone (large x1), no bladder tumour seen on X-ray.

I advised antibiotics and surgery to remove bladder stone 7 days later and 10 cans of S/D diet . Dog went home but did not eat the S/D as she did not like it.


3. Jun 14, 13
BLADDER STONE REMOVAL SURGERY
Dark brown cloudy urine seen. Not analysed to save money for the owner.
One large bladder stone of 1.5 cm across, taken out. Video and images.
"Need to analyse stone" recorded in the medical record as the owner took home the stone.

Follow up on Jun 18, 2013
Dog has more appetite and is active.

















 
 
 

A superfit weight-losing Jack Russell

"My maid said to me that the dog is very fat now," the man said. "Yet I can see that my Jack Russell is bloated with spinal bone protruding. Fat dogs don't look like this."  Sometimes I get challenging cases.


1.  May 30, 2013
JR , M, 6 years. Very thin at 6 kg. 
Abdominal distension but active and eating. 
No dyspnoea, coughing

In such cases, blood test and urine tests are basic. X-rays can wait.  Abdominal fluid must be drained and sent to the lab for analysis of the cells. This may be overlooked by the vet.

ABDOMINOCENTESIS
6 kg. Dom + Ket 0.1 + 0.15 ml IV. Drained >500 ml of abdominal exudate. 5 ml sent to the lab.


2.  Jun 1, 2013 lab report of abdominal exudate - cytology.
5 ml of pale yellowish fluid.  3Pap and one Diff Quik stained smears showed atypical epithelial cells.
The features are worrisome for an adenocarcinoma.


3. Jun 18, 2013
I phoned the owner. He said: "Superactive but losing weight. Can see bones protruding from his back. Just dash here and there. Jumps on me when I am home. Is there any cure? "
"No guarantee of cure," I said. "You may wish to try azathioprine tablets for 2 months."
"Any side effects?"
"Vomtiing and diarrhoea. Lower the dosage 

1470. The aggressive biting 3-year-old Corgi

A man brought in a 3-year-old male Corgi. "He bit my mother's hand," he said. "He jumped onto the sofa to get patted on his head as my mother used to do earlier but she was watching TV and so he just bit her hand. I want him neutered."

"Is she badly injured?" I asked as this Corgi has considerable strength and size.
"A big tear in her hand."
"Has he bitten other people?" I asked.
"The maid and snapped at my friend who wanted to pat him 6 weeks ago. Is it because my female Shih Tzu is on heat? I asked my children not to touch him as he growls at them. He only allows me to touch him"
"In theory, this dog should be put to sleep," I wanted to examine his mucous membranes as he was muzzled and put on the examination table. He growled, turned around and snapped at me. The man was the only one he does not bite.

"Why didn't you neuter him when he was younger at 6 months?" I asked.
"I don't like the idea. Besides, he does not bite till the last 2 months. Why?"

"He is a one-man dog. He had bad experiences of people or children pulling his tail or beating him when he was a puppy at around 2-3 months of age. So he does not like children."
"I give him a second chance. My mum visits me and does not stay for long and so I don't want to euthanase him."

What is the solution to stop him from biting people?
"Neutering may not help as he has developed a habit of biting people when touched. His canine teeth are strong and sharp and may tear the flesh of another person he bites."

Is there a solution to prevent an older dog from biting people?

1469. Trust & Audit of case - shih tzu with blood in the urine (haematuria).

Medical opinions by vets differ on how to handle a haemturia case in a dog. Some vets give medication and wait and see if any more recurrences happen. This is to reduce medical costs for the owner.

Some owners are reluctant to do further investigation when their older dog has blood in the urine as illustrated by this case.  In the end, the total medical cost is higher owing to more consultations.


Shih Tzu, M, 6 years 

1.  Mar 6, 2013 - Vet 1. Haematuria.  Urethral obstruction.  Unblocked bladder. Urine analysis and advised radiographs pending urine test. Differential diagnosis was UTI or stones. No X-ray was done.

URINE TEST
pH 7, SG 1.024, Blood +, Bacteria Occasional, Casts granular occasional, Crystals Nil

2. Mar 24, 2013 - Dr Sing Kong Yuen (myself).
Fresh blood in urine for past 2 days. No blood in urine since Mar 6, after medication.
I advised X-ray of kidney and bladder and urine analysis when there is blood in the urine after medication. I recorded "Thick bladder wall", prostate OK.

3. Jun 2, 2013 -Dr Daniel
Recurrent haematuria & diarrhoea. Dr Daniel recorded no crystals in March 2013 urine test. Advised X-ray.

Jun 4, 2013 - Dr Daniel
X-ray and urine test done.
URINE TEST

pH 8.0  SG 1.015, Blood 4+, WBC >2250.Bacteria 2+, Crystals Amorphous phosphate +



Cystotomy to remove one bladder stone by Vet 1.
Stone analysis:
Magnesium, calcium, phosphate +ve

CONCLUSION
Any advice on prevention?
No crystal in the urine does NOT mean no urinary stone
X-ray at first consultation of haematuria in the older dog would benefit the owner and the dog especially in cases of recurrent haematuria earlier. However economics dictate the owner's decision for X-rays. 

1468. Update: Matted Shih Tzu with bladder stone surgery - Hair inside the stitches when going home

TOA PAYOH VETS toapayohvets.com Date:   18 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits KPI - How long it takes me to remove a bladder stone in a poodle  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   18 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Monday, June 17, 2013 1468. Update: Matted Shih Tzu with bladder stone surgery - Hair inside the stitches when going home   Yesterday Monday, Jun 17, 2013, I was on evening duty after having time off to watch "The Man of Steel" at Ang Mo Kio Hub at 3.30pm. A male gold and white Shih Tzu with very thick coat that had bladder surgery by Vet 1 had come in for re-stitching. It seemed there was stitch breakdown and the owner claimed that all the time the Shih Tzu had been wearing the e-collar. By inference there would be no way that the Shih Tzu could lick the incision wound beside the penile length. The wife who came to collect this Shih Tzu said: "My dog had hair inside the stitches when he went back. There should not be hairs inside the stitches!"  I reviewed the case record. The Shih Tzu had been warded for 4 days and then sent home. Many owners are unhappy when their dogs return for wound breakdown and would blame the vet. I examined the dog's lower body and showed it to the owner. The whole of the lower body was clipped bald from the neck to the scrotum by Vet 1 before surgery. So there was no possibility of hairs being "stuck" inside the stitches. The owner had not cleaned up the stitched area. "If I was operating, I would have the whole dog clipped bald," I said to the owner. "Your dog has many turfs of matted hair in the hind legs and the whole body. In such cases, the vet should insist on the dog getting clipped bald as loose hairs from the matts could stick onto the wound. If the owner did not want to do it, then don't operate on the dog to prevent such complaints. "I have just operated on a bladder stone poodle with similar matted hair in her body and back and I got it clipped bald. There is no complaint about hairs stuck inside her stitches as she had no hair." The vast majority of dogs coming in for bladder stone surgery don't have matted hairs and so Vet 1 would not have thought of getting this one clipped bald unlike me.  I phoned Vet 1 and let her talk to him. But she did not mention about the "hairs being in the stitches" on handing over by him. She just asked about the medicine. A senior citizen was present in the waiting room and he overheard the complaint. As the dog was being discharged, the whole conversation demonstration were in the waiting room. He had come in to buy a special diet for his Golden Retriever who had put on lots of weight. This R/D diet gave instructions on how much to feed to target the ideal weight. The bag mentioned how many "cups" to feed or how many grams of the kibble to feed to attain the targetted weight. "Use grams as the American manufacturer's cup is not the same as the Singapore's cup. Usually I don't stock R/D bags as Singaporeans in general don't buy them although they are effective. But there is a bag I reserved for a lady who buys regularly and her Golden Retriever now is quite slim."  This gentleman is one of those rare kind men as he spends his money to bring the stray cats in his neighbourhood to be sterilised at normal rates, without quibbling with the vet to reduce fees to the bare minimum.  Most stray cat carers in Singapore are women and men are rarely seen.  "If a large  operating skin area is clipped, there is usually no complaint about wound or stitch breakdown," I said. "This Shih Tzu is badly matted but Vet 1 did not think of getting the whole body clipped clean before surgery. So loose hairs get "stuck" onto the stitches causing infection and irritation and stitch breakdown." "You are an old vet," the gentleman implied that experience counted. "I had a Husky and the Golden Retriever sterilised by you and I had no problem (of stitch or wound breakdown)." Frankly I cannot remember neutering his two big dogs but owners don't forget the operating vet who is responsible. For better or for worse.  "Sometimes, it is common sense," I said. "A badly matted dog must be clipped bald when there is major surgery." In this case, the dog had been clipped bald from the neck to the scrotal area by Vet 1. This was a large area as normally vets would shave only the lower half of the body for bladder stone surgery. Feedback from the owners is excellent if not viewed negatively. From now onwards, I instructed my assistant that all badly matted dogs must be clipped totally bald before bladder stone surgery as he had seen me doing for the poodle. There should be a proper handing over, with digital images taken during handing over and signature of the vet on the state of the sutures and wound on handing over. This is ideal but not done usually, even by me. A systematic process of handing over is best for all parties concerned and I shall implement it from today. Negative feedback is very useful as it helps to improve the service standard.     Updates will be on this webpage: www.sinpets.com/F5/20130618matted_hairs_poodle.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: June 18, 2013 Toa Payoh Vets

 

1465. Bleeding anal area - hamster

EMAIL TO TOA PAYOH VETS DATED JUNE 18, 2013
to judy

Hi Toa Payoh Vets,

I'd like to seek some advice with regards to my syrian hamster. She's about 2 years old and throughout the close to 2 years, this is the first time i'm seeing this. She is apparently bleeding from her bottom (anus to be precise). Last night i think i spotted some discharge, but this afternoon, it became a little bit of bleeding which then progressed to quite a bit of bleeding for a hamster. 

She is starting to sleep in places she don't usually sleep in and i'm really worried about her. It seems like moving around is quite painful for her. Should i bring my hamster in to get it checked? if so, how much would the total fees cost? 

hope to hear from you really soon. 

Cheers, 

Kong Yuen Sing <99pups gmail.com="">	6:31 AM (0 minutes ago)

It is best to get the hamster examined. The consultation fee is from
$35 to $50.

1466. Sunday June 16, 2013 - Interesting cases

I rushed to see the overweight Jack Russell who drank and drank for the past 2 days. As if he had diseases of the liver or kidney or diabetes after the 10 little bladder stones were removed by Dr Daniel 2 days ago. We did not do a blood test as there was a need to reduce medical costs for the taxi-driver owner, a white-haired gentleman from the heart lands. His friend and his wife came to visit the dog the past 2 days and therefore I deduced that this Jack Russell was much well loved.

There was another gentleman who loved his Poodle much too. Her bladder stone was solitary and removed by me and the dog went home the 2nd day after surgery yesterday as she was as active as before surgery. She did vomit yellow gastric juice after surgery, which was unusual. But she had kidney stones.

Both owners took home the urinary stones. They  were advised to do chemical analysis of stones but owing to economics, both did not do so and I did not insist since urine tests showed calcium oxalate for the Jack Russell and triple phosphate for the poodle. For the poodle, I strongly advised taking S/D to dissolve the kidney stones but it seemed that the dog would have none of the S/D. "Give 90% her food and 10% of the S/D first," I advised. Much depends on the owner's compliance.

As for the Jack Russell, I said to the taxi-driver, "No dry dog food, no dog treats. Just home-cooked rice and fish or chicken and vegetables."

----------------
Teach and learn for Intern Terrence

"Some interns can't solve the problem but you should be able to since you are from a top school," I said to Intern Terrence. "You are a student of Raffles Institution."  He was new to producing the first video for me, using Windows Movie Maker on a Samsung laptop. The problem was that there was no visual but voice only when he ran the video.  Two weeks ago, he replaced the Movie Maker by downloading a newer version. "It takes a long time to download," he said. Toa Payoh has poor internet connections although I have this dongle. Then I took the laptop to Khin Khin's Myanmar IT manager who did something and the visual appeared. "I studied computer for 4 years," he would not tell me how he did it.

However, the visual disappeared again and so I asked Terrence to spend half an hour researching Microsoft's FAQ which he did not do so last time. He did googled and got some internet forum but could not solve the problem.

This Sunday, he solved the problem within 5 minutes from Microsoft FAQ telling him to update one Window's file. So, he learnt a bit rather than just observing vet work. I asked him to video a white hamster with an orange stain on the left cheek and head tilting to the left. He was new to the video and some parts were blurred. Will need to teach him and learn more. I put the hamster and he videoed as it dashed towards him. There was now evidence that the hamster indeed tilted his head to the left, as complained by the owner! It is not easy as the head tilt was not obvious when the hamster was still, unlike in a big dog, rabbit  and cat.        

As to the cause, I anaesthesized the hamster while Terrence was supposed to video my work. The cheek pouch was impacted. Orange stain came from a soft food tissue embedded deep inside. Left ear not inflamed but irrigated. Left cheek commissures ulcerated. We have to wait and see if the head tile is no more.

1465. Saturday Jun 15, 2013 - interesting case - The cat who bit the vet

"My cat is constipated," the young  lady teacher said to me on Friday Jun 14, 2013. "He went into the litter tray and tried to poop but could not do it. He passed 2 hard lumps of stools and then nothing. He strains and strains."

I have treated this 10-year-old male cat for the past years, starting from his continual licking of his belly some 6 years ago. His belly became bald. It took some time for me to discover that the owner had been putting newspapers to cover the whole litter box and so he would soil himself after doing his business as he climbed out of the box. He would then have to clean his belly thoroughly like all healthy cats. So the belly and inguinal area become hairless. Changing the litter box management resulted in him getting back his belly hair.

Now he seemed to have constipation. I palpated a short roll of stools in his colon and asked Dr Daniel to manage the case. Enemas were given. Oral laxatives were given but there were no stools out the next day. Dr Daniel did advise X-ray if there were no stools. "How many ml of the oral laxative oil you gave?" I asked as the enema did not work. "2 ml," he said. "Well, it may not be sufficient. Give 10 ml."

Another enema was given. Still there were no evidence of poo in the sand litter box on this fine Saturday. The father phoned first and then the daughter as they were worried. Both came to the Surgery as I said they could bring the cat home to observe the effects of the laxative. In their presence, I check the cat's backside. A hard stool lump was stuck in the backside hairs. I removed it with a piece of tissue.

"What caused this constipation?" I asked the father and daughter. "Did the cat drink sufficient water?"
"He does not drink as he eats canned food," the father said. "Nothing has been changed in his habits and management."
"Are you sure? Did he eat plants?"
"No," the daughter said.
"He has a habit of licking plastic bags nowadays."
"There could be toxins on the plastic bags," I advised the owners to keep all bags which would not be practical.
I put the cat on the table for a final examination by palpating his abdomen. There was a large lump in mid-abdomen, about the size of a quail egg but roughly rectangular in size. A hair ball? This was a thick-coated grey cat. For some reason, the cat reacted to my palpation and sunk his teeth into my left wrist. A 2-cm red line and another 3 mm line oozed some blood as the cat's fangs must have cut the skin. I withdrew my hand and washed the wrist. The owners were as amazed as I was.

"Luckily it is not a claw wound," I said. "Claw wounds from cats get septic easily. He must have been fed up with my assistants giving him laxatives and enemas."

Quiet cats do bite but rarely. Cats usually hiss and claw. The cat went home and on Sunday, there was no call from the owner. I presume all are OK. Wiping the cat's backside with wet cotton was one of the procedures the owners did. They said they do not use the perfumed baby wipes and they did it gently. This wiping could cause painful anal area but it is hard to say what causes this "constipation" problem in an old cat that bit the vet. .  

 

1464. Myanmar stories - The man from Shwebo

Khin Khin had replaced the Man from Rangoon who resigned with a Man from Shwebo. I saw him at her office 2 days ago on Friday. The Man from Rangoon was also present.

"This is the man who resigned and therefore you got the job," I said to him. He is also a slim man, shorter than the Man from Rangoon and has a less dark complexion. He was from Shwebo, a district famous for its thanaka trees. If you visit Myanmar, you will not fail to see the ladies and some gentlemen with thanaka cream smeared on their cheeks and forehead. This is the culture. The cream comes from the thanaka trees.

"It takes 8 years for a thanaka tree to produce good thanaka," the Man from Shwebo said to me. "The stem is cut and ground in a stone plate to produce the juice. The best juice is from the stem of a thanaka tree grown for 8 years."

"Nowadays, it is very difficult to get a job in Singapore," I advised him to be patient and not resigned within 2 weeks as he had a son and wife to support in Myanmar. "You will work 10 hours a day and have a weekday off, according to the Man from Rangoon. There will be supervisors scolding you. Be patient. Work for a year."     

"Singaporean employers want young employees and fairer complexion," Khin Khin asked and was told that the Man from Shwebo was 35 years old. The other man was 38 years old.

"The Myanmar supervisor will want to get rid of you," Khin Khin said. "So he will shout at you for being slow and inexperienced if you are hardworking, like the Man from Rangoon. The boss is uncouth and uneducated and does his shouting too."

Actually, according to Khin Khin, the main reason for the resignation of the Man from Rangoon was that his wife, working on a work permit in Singapore had Sundays off while he would only be given a weekday off per week. So he would not able to see his wife. The wife of the Man from Shwebo is in Myanmar and so he could work hard, I hope.