Monday, January 30, 2012

853. Day 2 of travel. The Balinese and Pushpapuri Villa

Jan 30, 2012 Sanur, Bali, Pushpapuri Villa

Some info about the pictures I took from the Pusphapuri Villa and the Balinese culture

The Balinese are Hindus although Indonesia is predominantly a Muslim country.
Most of them live in a village (desa) which has 3 main temples (pura). These are the origin temple (pura puseh), the village temple (pura desa or pura bale agung) and the death temple (pura dalem). All villagers worship at these temples.

I had a unique chance to talk to the Manager of the Pushpapuri Villa on arrival on the morning of Jan 29, 2012. He told me that the temple on the left was the death temple. I could visit it but must wear a sarong (skirt-like). I could borrow one from the staff. In the death temple, no ashes are put there. All bones are crushed and ashes in a piece of cloth are scattered into the sea. Those Balinese who can't afford the costly cremations will bury first. Later, the government will offer money for a mass cremation and each family is responsible for the preparation.

Each village has a hamlet (banjar) which is the community. In each hamlet, there is the elected leader and another government appointed leader. There are cooperative groups of neighbours to help each other. The worst punishment is to be exiled from the village. So all Balinese have roots and are never isolated.

He said Mount Agung has not erupted since 1963. I wanted to visit it or trek but it is drizzling this morning Jan 30, 2012.

BEACH CLEANING
"The old man comes early to pick up the plastic bottles for recycling," the young Manager who is in sole charge of only Pushpapuri Villa and no others said to me. "Later there are women who come to clean the beach in front of the villas. In the afternoon, I saw two cleaners.

SECURITY GUARDS
At 3 am I woke up to listen to the sea waves. There were two men in their 30s patrolling the garden and checking the beach for intruders. One of them appeared to carry a short knife. I was impressed with the security of the management. It was drizzling but no thunderstorm. The waves roared. No brilliant blue sunrise and flashes of lightning as yesterday (some pictures to show what I mean). I guess I was lucky to have such good pictures. It is a pity that the website of this Villa has not much images of the beautiful surroundings and its activities. Yet February is fully booked.

BUILDING QUALITY
Other villas had collapsed due to poor construction but this villa is solidly built and was built in 2007. It is well maintained as I can see from the cleanliness and the structure. The only disadvantage is that the master bedroom has no power point on the dressing table for me to write and use my computer at 3 am. There are no writing tables in the master bedroom at all.

There is a library but somebody may be sleeping on the couch if there are more than 8 people. Sometimes, the architects may plan for what they think the user should do. So, no writing table in the master bedroom.

The same applies to some vets and groomers. They think what the client would want but is actually mistaken. For example, some groomers clipped the coat but leave the head and a bit of the tail end with hairs in a skin-diseased dog. This is not what the owners want. For vets, they may want blood tests and all tests to be done but this may not be what the owners can afford or want.

As I write, it is drizzling. The old man had come to collect the bottles and gone. Another man in the distance, near the death temple appeared to collect bottles. Plastic bottles can be sold for recycling. But this beach yields a few when the tide comes in. Still, I am inspired by this old man who still comes when it is drizzling. Now he has a competitor but that man came later. The waves are now stronger. Grey blue sky. No beautiful sunrise. The young men have not come back from their party which is an hour's drive away. It is already 7.20 am. I wonder what has happened to them.

852. Exile from a village in Bali

Jan 30, 2012

There is one village in Bali that has traditional houses in the whole village and popular with tourists. It does not permit any villager, no matter how rich he is, to build grand houses. Any villager who is found to be against the interest of the village will be judged by the elders and exiled. Exile is the worst punishment for the offender, said the hotel manager of the Pushpapuri Villa. The rich man can build his grand house elsewhere and will still be permitted to attend to the customs and visit his family.

The local head and the government representative work together in the village. There may be over 100 villages in Bali. Singapore has its RCC, CCC and the mayor.

There was a case of a surgeon who falsified his surgical consent form and I believe, all hospitals will ban him from operating in their theatres. Professionals need to obey the rules of the trade too or face exile. I heard of a story of a lawyer who applied to be reinstated as he was banned for conveyancing misdeed. He did not mention about some misdeed in his application for reinstatement. So, he was not given back the licence.

There are rules and regulations of a society that a young adult wants to rebel against. The consequences may be bad for them and they may need to think of the consequences.

851. Badung Strait, Sanur, Bali

Jan 30, 2012 Monday.
3.02 am, Sanur, Bali, Pushpapuri Villa

I went out to view the sea as I had waken up at 2.30 am as my iPhone rang. I usually wake up around this time.

Two security guards were patrolling. Young men in their 30s were flashing their torchlights towards the sea. There is a retaining wall but it is easy to climb up. However, this village area appears to be peaceful and safe and more beachfront houses nearby are being constructed for sale.

Pitch black night. No stars. Relentless pounding white waves towards the beach remind me of the intense competition in the real world of Singapore. Lightning flashes in the distance. Mount Agung cannot be seen now, being so dark. Yesterday dawn, after a heavy thunderstorm the night before, I could see Mount Agung and took some beautiful pictures. Then during the dog, a fog started appearing on the mountain top and in the afternoon and evening, Mount Agung was invisible. It is an active volcano, the last eruption being in 1963. The whole area was blanketed with volcanic dust for a month, according to the young manager in charge of this place. He was not born yet but his father had told him.

I was invited by Daniel to stay with his friends at this luxurious 4-bedroom real beachfront villa which rents from US$850 per night.

Its website is at:
http://www.pushpapuri.com/ in Bali. Built in 2007 by an Englishman and managed by Bali Hotel Management. Solid construction and well designed in an elevated ground so that the guests can see the waves directly from the dining room which is further away from the pool and manicured carpet grass garden.

This is my first visit to Bali which I knew was a famous tourist place for young people in the past. Two Bali bombings in the past had discouraged me from visiting this world famous place but all countries would have terrorist bombings now and then. Singapore had one in the 1960s.

Service and facilities are very good in this class of luxurious villas based on my reading of other similar properties. Black sand from the volcanic ashes instead of white sand. Can do surfing here as I saw some young men doing it. Good for families. Peak season in Christmas and New Year and around June/July.

There are 13 staff including 2 cooks. A driver with 6-seater SUV is on call. The Villa is well located and gives an excellent view of the Badung Strait, the Hindu temple, a river and Mount Agung and some islands in the distance. Good views for photography and painting. The surrounding areas have plots of farmland. I saw rice and corn fields with crops growing. Durian seller on the roadside. Wood and statues are seen everywhere in this area. Motorcycles and cars seem to be in large numbers on the main road outside.

Yesterday, I did not go to the bars unlike the young people as I know the party will end past 4 am. Young adults seem to love this type of entertainment with loud music and alcoholic drinks. Probably some drugs.

I had my discos in the 1960s and now they are called bars and pubs and are not for the senior citizens. I also did not go out at night to the busy night market to do shopping for T-shirts and bargains.

For young people, my advice is that life is unpredictable and they must stay healthy as the pounding waves of changes in the real world to earn a living are relentless. If the young people cannot stay healthy (being sleepy at work due to late nights), they become ineffective employees and unless they have certain skills in great demand, they will be replaced and sacked. The commercial world demands performance as not every business, including veterinary practice will succeed in the long term if they have sleepy not interested veterinarians. The bad word of mouth will spread and soon the practice is not well patronised.

Sunday, January 29, 2012

850. Minimising complaints and litigation against vets at Toa Payoh Vets

Bali, Indonesia, Jan 29, 2012. 12.23 pm

In Bali, I have time to reflect on the plans to make Toa Payoh Vets one of the top 5 vet practices in Singapore. New clients have come in from other parts of Singapore probably from the internet and some old clients of 10-30 years ago have returned to consult me. "The vets are very young," one mother of two young men said to me when she saw me after an absence of 10 years. Her sons had brought the 11-year-old Jack Russell with a big swelling below the right eye and they are now in University. Of course, I did not know that the mother had brought the Jack Russell to see me 10 years ago till she told me. I was phoning her sons to bring the dog home on Day 3 and she was in the Surgery visiting the dog. The dog was barking like nothing had happened to his loss of masseter muscle tissue eaten up by bacteria. Big hole if you see the images.

The mother identified herself as the owner of the Jack Russell and said to me that for convenience, she had gone to other vets. "You still look the same," she complimented me. I was surprised and happy to see her and the two boys who have grown so tall.

I guessed the other vets closed on the 2nd day of Chinese New Year and I was on duty. So that was how we met. I said to her, "All vets started young. They have to learn from being hands on over the years and gain the experience."

COMPLAINTS AND LITIGATION AGAINST VETS
In 2011, there was no complaint or litigation against the vets of Toa Payoh Vets. This is not a given.

1. One way to minimise complaints is for me to check all cases done by my younger vets. Sometimes I am inside the consultation room with Dr Vanessa Lyn, Dr Jason Teo or Dr Daniel Sing to assess their management of the cases. The new vets may feel uncomfortable as this may give an impression to the client that they are being supervised. They prefer to be alone with the client, thereby generating confidence. But this is not the way to increase the standard of care.

As an experienced older vet and the licensee, it is my duty to mentor the younger vets for the long-term good of Toa Payoh Vets. I have explained the rationale to them. "A complaint to the AVA or litigation takes up a lot of time and will involve me as a licensee', I said to them. "My licence can be revoked for failure to ensure an expected duty of care by my vets."

2. The internet complaints are the worst and I did come across one or two complaints of poor service by Toa Payoh Vets and also good comments. There were some clients who consulted me due to some good comments.

Recently I read in an internet forum about complaints against a brand name vet practice. Just one vocal writer but there were others agreeing with this writer. Another complimented about excellent services from another practice and got blasted for "advertising" for this practice. An ex-employee vet of the brand name practice put up a defence that the vets were good but that was some years ago and got blasted. There should be a law requiring internet complainants to reveal their real names as it is very easy to libel others under the cloak of anonymity. So far, I have not come across such venom as in the above-mentioned internet forum.

So, the associate vets or new vets must tolerate my presence and intervention and be humble. There are predatory vets in the regulatory field and amongst competitors and so, it is not as simple as in the university attending lectures and passing examinations.

In the real world of private practice, there are many aspects involving the bottom-line and younger vets must be able to accept and comply with instructions from me. Recently, one associate wore slippers to work. The excuse was that she forgot to change to shoes. A few days later, she wore slippers again. Her excuse was that the dog had peed on her shoes and therefore she had to wear slippers. I had told her that one Saturday when I dropped in (I don't work on Saturdays) and saw my vet assistant Mr Saw and old man James all wearing slippers. I have dropped hints that slippers are not permitted.

Young vets are role models for the staff as they are in the top of the ladder. If they dress casually, come to work late and go off without warning or do not bother with the management in my absence, the staff will do what they like. First impressions do count a lot to clients. If the vet and the staff cannot be bothered with their office wear, what about their standard of care? It is likely to be casual too.

I have decided that associate vets who don't accept instructions again and again will be, to put it frankly, sacked on the spot. The vet may be most popular but he or she can open their own practice and do what they like. Such behaviours cannot be tolerated as it affects the morale of the lay staff and the reputation of the practice in the long term.

849. Owner's e-mail query about spaying a young Chihuahua

Sun, Jan 29, 2012 at 10:59 AM, <...@gmail.com> wrote:

Hi,

I would like to inquire what is the cost for the above?
She 7 months old and just began her season today, 29/01.
When is a good time to have the procedure?
Will she require hospitalization?

What are the possible side-effects?

Regards,
Name given

E-MAIL REPLY FROM DR SING DATED JAN 29, 2012

Thank you for your email. I am Dr Sing from Toa Payoh Vets. The cost of the spay is around $250 depending on whether there are complications. Best time to spay her is 2 months after the end of her season ie. around April 1, 2012. She does not need hospitalisation normally. Bring the dog in at 10 am and bring her back, usually in the evening. Appointments are best.

Possible side effects of surgery are anaesthetic deaths, infection, bleeding and pain. A blood test is advised to screen the dog's health and if there are no disorders of the kidney and liver, the risks are very low. As for bleeding and pain, there are prevention of further bleeding by careful haemorrhage control and check up. There is medication to relieve pain and prevent infections post-op.

In my experience of spays over the past 30 years of small animal practice, 99% of spayed cases of young healthy dogs do NOT die from anaesthetic risk as anaesthesia is safe nowadays. They do not get bleeding to death, infections or stitch breakdown. The majority of my dog spays are done during 2-3 months after the season.

Pl make an appointment at 6254-3326 for surgery. Best wishes.

Saturday, January 28, 2012

848. The dog passes gas for a long time - flatulence

I followed through today by phoning the owner. Some 5 days ago, his wife brought a container of semi-wet greenish stools, a medical swab of blood-stained vomit to me.

"My dog vomited blood", she had also told me she was a nurse and her husband was a doctor. They don't self-treat their own dog. The two samples were useful. I got the stools sent to the lab and the blood tested.

That was some 5 days ago. "Farting for so many months is not a normal thing for a dog or human being," I said. "There is something wrong with the stomach and intestines. So you get gas production and then smelly stinky smell in the room. If not treated, the intestines can get much irritated leading to "telescoping of one segment into another (intussusception) or rectal prolapse,"

This appeared to be a simple case of vomiting of blood. But the main problem could be the gastrointestinal system causing flatulence for very long time.

I gave the dog a 500 ml IV drip, antibiotic and anti-spasmodic and boarded overnight. I recommended the Prescription i/d canned diets for 1 month. No treats and any other food. Just the i/d 1.5 cans per day.

Now 5 days later, the husband answered my phone at 4 pm (Air Asia plane to Bali delayed as it was to leave at 4 pm, so I typed this story).

The husband said first: "The stools are solid for the first time. Where can I buy it? It is not sold in the shops."

Performance counts. This is what I always tell my younger vets. Stop the vomiting and flatulence. I did not give anti-vomiting injection at all. Just treat for chronic enteritis. You get good clinical outcome after the visit, you get referrals. As simple as that.

The stool sample showed blood but no white cells or parasites. The blood test was not significant. I/d for one month and go on good quality food and treats. The cheap treats sold at Singapore's pet shops should not be fed to your dogs as they are cheap for one reason.

847. MYANMAR STORIES - An 82-year-old father in Yangon can't sit up at all. Renal Cortical Carcinoma.

28 Jan 2012. 

"Why can't my father sit up for more than a minute?" Khin Khin asked me. Her father had difficulty in breathing and lower back pain on the left and she went home to Yangon to get him treated by the Specialists. I rushed down to her Peninsular Office to see if I could help as her father was 82 years old but had alertness of mind and body. "He can walk to the hospital but nowadays, he can't sit up," Khin Khin was sad.

Basically, I checked the drugs given to him asking her to google for info since a doctor in Peninsula Plaza told her that he did not know about the drugs given to her dad. Tramadol, Lyerica and celophrix (non-steroidal anti-inflam). No wonder he could not sit up as the first two cause drowsiness. Being so old, his body could not eliminate the drug fast like a young person!

With this knowledge, what did Khin Khin do? Nothing. So today, before I left for Bali on Air Asia, I followed through and phoned her to ask the father to stop taking the 3 drugs if he has no more pain (CT scan catheter in Yangon via femoral vein had hit the kidney and cause intense pain, Khin Khin said).

If pain returns, take the Tramadol first and consult the doctors for a review. For 2 weeks, the poor father could just lie down the whole day and night and had no appetite. I asked Khin Khin to speak to him over the phone. He could not answer me promptly as if his throat was choked. Most likely water in the lungs had returned. But there was some medicine to reduce the phlegm and none to remove the lung oedema. The CT scan said there was an atypical RCC (Renal Cortical Carcinoma). 

If her father could sit in the wheel chair, his daughter would spare no expense to fly him to Singapore for a second opinion. I had met the father in Yangon when he was in good health.

He was a very intelligent educated man, working during the old British colonial days of Yangon in a bank. 

It is so sad that he could not sit up for a minute and was vomiting and drowsy and did not enjoy his life. That was why he had not want to go to the Hospital but his daughter got him there. Now he can't walk!

FURTHER TESTS in Yangon showed he had kidney cancer. He passed away later.