Medical Trainee Curriculum

Day 1 - Basics 

Please watch the Intro Video and read all the Day 1 information including the links before your first shift 

Introduction

The first day of parvo training presents a lot of information very quickly. You are not expected to know everything after one read-through, but you will be expected to answer some questions during training by using critical thinking. Reading the curriculum beforehand should make remembering easier and make the first day less overwhelming. Here’s what you should expect to do on your first day:

  • Learn how to enter the Parvo ICU correctly (Do not enter the Parvo ICU past the clean side without being shown how to enter!)
  • Tour the Parvo ICU so you will have a basic idea of where everything is
  • Learn how to do parvo laundry
  • Review the causes of death from parvo and how a shelter can address those causes of death in our parvo treatment protocols
  • Learn how to use the Patient's Medical Chart
  • Learn how to perform a basic physical assessment
  • Draw up SQ medications
  • Watch the trainer administer SQ medications and fluids to a dog
  • Administer SQ medications and fluids to at least one parvo dog
  • Administer oral medications
  • Learn feeding guidelines
  • Learn to monitor and note puppies’ food intake, defecation, and vomiting
  • Clean cages
  • Fold laundry
  • Learn how to leave the Parvo ICU correctly so you avoid spreading the virus to your own pets or other dogs in the facility

Hand Washing

  • Medical hand-washing, more thorough than typical hand-washing, is the most important method to prevent spread of disease and should therefore be done frequently and thoroughly.
  • You must wash hands between each and every patient. Many of our patients have diseases in addition to parvo such as upper respiratory infections, mange, or even distemper. Washing hands in between patients is essential to prevent these diseases from spreading, which is important since any extra medical condition can reduce a patient’s chance of survival.
  • Please read the following protocol for Medical Hand-Washing.

Entering & Exiting the ICU

  • Before entering the Parvo ICU, we change out of street clothes and into the parvo-designated scrubs following a specific protocol. It is very important to follow the protocol exactly to avoid spreading the virus to the clean side of the changing area, other dogs in the shelter, or your own home.
  • You will not wear you own clothes while in the Parvo ICU , we provide scrubs that stay in the Parvo ICU because they are considered contaminated with parvo. Your clothes will be left in a locker on the clean side.
  • Please read the protocol for entering and exiting the Parvo ICU here.

Attention to Detail

It is very important that all volunteers pay attention to detail. Volunteers spend much more time with the patients than the doctors do, just as nurses do. You are the doctors’ eyes and the patient's voice. Let the doctor know if you notice pain, sneezing, congestion, nasal discharge, hair loss, or any other new or changing symptoms.

Parvo Disease Basics

Parvo is a virus. This means that we cannot cure the virus itself, because antibiotics do not kill viruses. We can only offer supportive care until the dog's own immune system is able to fight off the virus. Parvo is transmitted via "fecal-oral" route, meaning the virus is shed from the feces, which can also infect the environment. Another patient can then ingest virus from the environment, or directly from infected feces. Parvo is an incredibly hardy virus and the only household disinfectant that will kill the virus is Bleach at a 1:30 dilution (or stronger). To contain the virus from sick patients, we have a designated Isolation Unit and follow quarantine protocols.  Please review the page What is Canine Parvo Virus? for more detail.

Symptoms

  • Inappetence (also called anorexia in vet medicine)
  • Lethargy/depression
  • Nausea
  • Vomiting
  • Diarrhea
  • The diarrhea is often extremely liquid may consist almost entirely of blood

Causes of Death

  1. Dehydration
    • The virus is attacking and killing the layer of cells that line the puppy’s GI tract. This makes it impossible for them to absorb liquids or nutrients and causes vomiting and diarrhea. This rapidly leads to severe and life-threatening dehydration.
    • Dehydration is treated with fluids to rehydrate the patient and sometimes antiemetics (mediations that prevent nausea and vomiting).
    • Fluids can be administered in several different ways:
      • Subcutaneous (SQ) Administration: Fluids can be administered under the skin(SQ) with a needle, as demonstrated below.

        SQ Fluids for Dogs and Cats


      • Intravenous (IV) Administration: fluids can be administered directly into a vein through an intravenous catheter. IV fluids can be administered
        • As a bolus- a large amount of fluid given quickly
        • As a CRI (Constant Rate Infusion) using an IV pump. This allows us to give a dog a certain number of milliliters per hour, 24 hours a day.
  2. Secondary Bacterial Infection
    • Parvovirus also kills rapidly-growing White Blood Cells which normally fight off infection. As the puppy is fighting off parvo with a depressed and overburdened immune system, the patient becomes more susceptible to bacterial infections they would normally be able to fight off.
    • In addition, the puppy’s compromised intestinal tract may begin to allow normal gut bacteria into the bloodstream, where they can wreak havoc.
    • Once infection penetrates the bloodstream—a condition called sepsis—it spreads to the entire body and causes the patient's system to go into shock.
    • We use antibiotics to combat these infections and prevent them from causing shock.
    • We also use sterile technique to prevent secondary bacterial infection from arising.

Parvo Medications

  • We administer medications through several routes:
    • Orally (PO)
    • Subcutaneously (SQ)
    • Intravenously (IV)
  • We use several types of medications
    • Antibiotics - to prevent and treat sepsis
    • Antiemetics - to reduce and prevent nausea and vomiting
    • Fluids - to prevent and treat dehydration
    • Antiparasitics/dewormers- to kill intestinal parasites
    • Antacid s- to reduce damage to the stomach and esophagus from vomiting stomach acid
    • Pain medications
  • Treatment Order
    • Triaging - determine which patient is the most critical and treat that dog first (unless otherwise indicated)
    • Treat dogs with URIs, mange, distemper, or ringworm last because these conditions are contagious to other dogs

Patient's Medical Chart  

 
A larger image of a Patient's Medical Chart can be viewed here

Physical Assessment

  • Doctors use the volunteers’ observations to determine the treatments, so this is very important
  • We look at several parameters to determine overall health
    • Attitude is their demeanor which can be observed from outside the cage. 
      • Are they bright, alert, and responsive (BAR), like a normal, healthy puppy?
      • Are they quiet, alert, but responsive (QAR) to your presence or movement/noise?
      • Are they lethargic - little response to your presence, laying?
    • Gum color is an indication of blood circulation or perfusion. Healthy gums are bubble gum pink, but can also have purple pigmentation on the surface.
    • Temperature
      • A dog’s normal temperature is between 99.5 and 102.5
        • Fever is an indication of systemic infection
        • A low temperature is an indication of shock
      • The temperature of extremities, such as paws, can be an indication of perfusion. A dog’s paws should feel warm, while cold paws are an indication of possible shock. Check the webbing between toes if the patient is on stainless steel 
    • Hydration
      • If a dog is dehydrated the skin will not immediately spring back into place when pulled up or pinched and his gums will feel tacky.
    • Absorbance of SQ fluids
      • Check the chest and under the arm pits to see if SQ fluids, which are administered between the shoulder blades, were not absorbed and have been dragged down by gravity.
      • If SQ fluids aren’t absorbed then the dog may need to be switched from SQ to IV treatment
Medication Section
  • Medications and doses are prescribed by the doctor based physical assessment
  • Check boxes denote when each drug is to be given. If there is no box, that medication should not be given that shift.
    • Check or X the box after you have given a medication.
    • If a box has a horizontal line through it, it either should not be given (is discontinued by the doctor) or was not given.
  • Draw up your medications and label the drug name and route it is to be administered.
Intake and Output = Consumption and Excretion
  • Feeding Guidelines
    • Always initially offer just a spoonful or small meatball size of food initially. Don’t waste a whole bowl of food if the dog is not going to eat.
    • If the dog is drinking water but not eating, offer wet food or baby food mixed with water. This allows them to get some protein, even if just a little.
    • Only offer a half bowl water to dogs that are frequently vomiting. Parvo dogs get very thirsty but if they drink a lot it will make them vomit more.
    • Always remove food from a nauseous dog’s cage. We don’t want them to make them feel more nauseous than they already are. Dogs also have smell memory and, once feeling better, will still get nauseous when smelling a food that made them nauseous before.
  • Record all food consumption, vomit and feces
    • Note quantity, color, consistency, if there is blood, and anything else abnormal. Doctors will review your notes to edit the treatment plan as needed.
  • Cage cleaning
    • All feces must be flushed down the toilet. You should flush poop instead of throwing it away to prevent the spread of parvo to other parts of the facility
      • Do not clog the toilet
        • Only flush fist-sized amounts of feces/toilet paper at a time. This may take several rounds! Be patient.
        • Do not flush paper towels
        • Watch to make sure everything goes all the way down
    • Replace blankets only if they are sufficiently wet or soiled.
Review the Medical Volunteer Expectations, if needed.

A word document with the Day 1 information can be downloaded from the bottom of the page.

End of Day 1 Quiz

Complete the quiz below and check your answers by clicking the "View your score" link once the quiz has been submitted.

End of Day 1 Quiz



Day 2 - SQ

Previous Day Review

The following official Protocol Pages will provide more thorough detail to the overviews given in Day 1 of the curriculum. Please read through all provided links.

Subcutaneous Treatment Practice

  • By Day 2, you should be familiar with Baytril, Polyflex, and Reglan. Know the type of drug, routes and special notes. Go to the Drug Chart page to review these. You should begin studying other medications on the chart as you use new drugs.
  • When a is a puppy on SQ vs PO or IV meds?  Dogs larger than ~5 lbs will initially start on SQ medications given under the skin if they are not showing severe symptoms (lots of vomiting, bloody diarrhea). SQ medications can be effective for dogs that are absorbing the medications effectively.
    • Three reasons to switch from SQ to IV:
      • When the puppy is lethargic
      • If the puppy is not absorbing SQ fluids
      • If the puppy has excessive excretion (bloody diarrhea, vomitting excessively)
    • Two main reasons to switch from SQ to PO:
      • If the dog is eating half of a meal or more
      • If the dog is squirming excessively when giving fluids - must also be eating some
  • Review standard SQ treatment
    • Baytril, Polyflex, Reglan, and Fluids are the main SQ treatment medications you must be familiar with.
      • Doses for each dog can be found on the Drug Charts and Terminology.
      • What is the purpose of each of these common SQ medications?
      • Know all of the special notes and routes for these medications. What do you think may happen if a SQ only medication is given IV?
        Answer: The dog is likely to have seizures and/or die from being given a SQ medication that is not meant to be given directly in the blood steam.

Medication Review

  • Review/skim through the following information to begin familiarization with medications using the Drug Chart.
    • Types of fluids to be used SQ vs IV 
    • Types of anti-emetics and their strengths 

End of Shift Responsibilities


End of Day 2 Quiz


End of Day 2 Quiz


Day 3 - IVs

Previous Days Review 

Be able to answer the following questions. Review protocols if unable to give succinct answers.
  • What is the importance of scrubbing in and out properly?
  • When do you switch a puppy off SQ treatment to PO meds? SQ to IV?
  • Why do SQ fluids not absorb completely in some patients? How can you tell?
  • What are the drug types, routes, and dangers of the following drugs?
    • Baytril - what is the drug name (Baytril is the brand name - the drug bottle may only say the drug name)
    • Polyflex - How must this drug be stored?
    • Reglan - How must this drug be stored?
  • Why is a dog switched from SQ to IV medications?
Review the following protocols 
  • Sterile Guidelines Review
  • Feeding Guidelines 
  • Cage Cleaning 
    • Only change blankets if they're sufficiently soiled
    • Always dispose of feces/solid materials before placing in laundry bin.

Introduction to IVs

When patients become more critical (lethargy, pale gums, increased vomiting, and/or bloody diarrhea), they are placed on IV medications and IV fluids as a constant rate infusion (CRI) continuously throughout the day. This is accomplished by placing an IV catheter. The IV catheter must be maintained properly.
  • Important checks prior to treatment include the following:
    • Swelling above or below the catheter
      • Paw swelling below the catheter indicates the tape or vet wrap is too tight
      • Arm swelling above the catheter indicates the the vein may have ruptured, or blown, and the patient needs a new catheter
        • A blown vein will leak blood in the surrounding area, causing swelling 
        • Swelling from a blown vein is generally above the catheter site due to direction of blood and IV fluid flow
        • A blown vein will clot on its own when its able to "rest" after the IV fluids and catheter have been removed.
        • A different vein/arm must be used for a new catheter.
        • The swelling is often painful depending on severity. A special bandage may be needed to prevent infection.
    • Flushing the catheter
      • Plain LRS or NaCl fluids can be injected into the catheter to check for patency, meaning there are no blood clots clogging the catheter and that the vein has not blown. A patent catheter will have minimal resistance when pushing/administering the flush. 
        • If its a blood clot: There will be moderate to high resistance. Remove the clot by pushing the flush through it, or carefully remove any visible clots with a needle. 
        • If the catheter is blown: There will be low to moderate resistance and swelling above the catheter site.
      • Flush before, between and after medications. Only use however much is needed - as little as 0.2-0.5mL.
      • The drug Heparin, and anticoagulant, is often added to the flush to help prevent blood clots forming inside the catheter
  • Catheters should be changed every 72 hours
  • The IV Catheter port (orange/yellow parts in the picture above) is where medications are injected, and should be cleaned with an alcohol swab prior to administering medications.

IV Medications

As a general rule, most IV medication are clear in color and nothing colorful should be injected IV.  The most common result of injecting a drug not meant for IV use is seizures and/or death. Never inject something into a dog without knowing what it is and what route is safe.

See the following for images of each drug/LRS:
  • IV CRI - Patients are typically on an IV CRI for several days until they start eating again.
    • Lactated Ringers Solution is the most common and affordable crystalloid fluid solution given IV. 
    • Always read the full name of the fluids/drugs before drawing up or administering anything.
      Sometimes donations will have LRS + Other Drugs. 
    • Additional medications can, and frequently are, added to the fluid bag depending on need
    • Review the three common drugs added into a fluid bag to be given as a CRI
      • Dextrose - sugar
      • Reglan - anti nausea
      • KCL (Potassium Chloride) - electrolytes
  • IV Drugs - Some drugs are administered every 8-12 hours instead of as a CRI. These drugs are given by medical volunteers in the AM and PM shift.
    • IV ports are cleaned with an alcohol swab before injecting medication into them
    • Don't forget to flush before administering any medications via the catheter!
    • Review the following common IV medications on the medical chart page.
      • Ampicillin and Cefazolin (antibiotics)
      • Famotidine (antacid)
      • Cerenia (antiemetic)
  • Intro to Hetastarch
    • Hetastarch is a colloid fluid that contains proteins, unlike crystalloid fluids (LRS). Protein helps draw fluid from outside cells into the blood vessels, this increasing blood volume and pressure. Increased pressure helps improve circulation to all internal organs.
    • This drug is typically used on critical, and/or crashing dogs, especially when their gums are pale/grey/white. It is most commonly given as a bolus in the AM and PM shifts. It will be prescribed, for example, as "Hetastarch 50mL over 20 minutes". You must be able to calculate what fluid rate (mL/hr) to set an IV pump to.
    • Some dogs may be on a Hetastarch CRI to replenish and maintain protein levels
    • Dangers - this drug must be given slowly, and can only be given a certain amount (depending on weight) a day. Overdosing can cause severe fluid overload, fluid in the lungs, and/or internal bleeding. Use caution with this drug and triple check dosage and time.
    • The most critical patients will be on Hetastarch, especially with severe bloody diarrhea, pale to grey/white gums, and/or severe lethargy. 

IV Pumps

An IV Pump is used to administer a CRI (constant rate infusion) of fluids throughout the day. They are generally simple to use, but small mistakes can result in severe medical consequences. Carefully check that the IV Pump has the proper settings with every use.
  • The two setting you are responsible for setting every shift include the 'Volume To Be Infused', or VTBI, and the Rate
    • VTBI
      • The VTBI, also called 'Preset' on some pumps, is the total volume of fluid that will be administered to the patient.
      • For Hetastarch, set the VTBI/Preset to the dose prescribed by the doctor (i.e. 50mL)
      • For a CRI, set the VTBI to 9999mL, as we are unsure how many days the patient will continue to be on IV fluids
    • Rate
      • The rate is always prescribed in mL/hr and NOT drops/mL
      • The doctor will prescribe the fluid rate in mL/hr (i.e. 12mL/hr) based on the patients body weight
      • The Hetastarch rate must be calculated. If the doctor prescribes 50mL over 20 minutes, set the rate to 150mL/hr and the VTBI/Preset to 50mL. The IV Pump will administer Hetastarch at a rate of 150mL/hr until it has given 50mL

End of Day 3 Quiz

  • When can puppies be moved off IVs?
  • How frequently should catheters should be changed?
  • How much Heparin is used to make up a flush?
  • What unit should the pump rate be set to? What will happen if it is set to the incorrect unit (drops/min)
  • Ampicillin and Cefazolin will cause nausea and vomiting if given too ______. 
  • The SQ version of Ampicillin is called _______?
  • Which drug, occassionally used in fluid bags for CRI, will stop the heart if directly injected into the patient?
  • We cover the patients fluid bags because one of the drugs is light sensitive. Which one?

Day 4 - IV and SQ Practice

Other Diseases

Many of our puppy patients have other diseases which will be treated concurrently. Volunteers and staff must take care to not spread diseases between patients. Some of these diseases are also contagious to humans. See Isolation Protocols for proper protocols to prevent spread of other diseases within the Parvo ICU. See the following pages for common diseases found in shelter dogs:
  • Distemper
  • URI
  • Ringworm
  • Mange (two types)
  • Intestinal Parasites (Worms)
  • Ticks
  • Fleas

Review/Practice

  • Sterile Guidelines Practice/Review - at this point with continued review, you should be realizing how crucial it is to always be thinking about sterile technique in storing and administering drugs.
  • IV Treatment Page - review important information, study the less common drugs used and  learn about IV treatment structure
  • SQ Treatment - review only if needed
For your next training shift, you will be practicing more IV patients as well as SQ patients. Let your trainer know where you need the most practice still. Expect to be quizzed on the drugs being used on your patients. You should be familiar with all primary drugs in the ICU by now (Baytril, Polyflex, Reglan, Ampicillin, Cerenia). Reference the Drug Chart when needed. 

Shift Structure

  1. Enter the ICU following proper quarantine protocols
  2. Start of Shift Responsibilities
    1.  Do a quick walk-through the entire ICU to look at all patients and determine who is the most critical. Some patients may need emergency treatment if unresponsive during the walk-through
    2. Start the laundry - every volunteer and staff member is needed to keep the ICU clean and organized
  3. Pick 2-3 medical charts at a time, starting with the critical patients, and start drawing up meds for multiple patients
  4. Treat patients
    • Check gums, paws, and for edema (fluid that hasn't been absorbed from last SQ treatment)
    • Check catheter for patency and swelling
    • Administer medications
    • Offer a meatball size amount of food to patients. If showing signs of nausea, remove food from cage. Replace water bowl
    • Remove any solid materials from blankets with toilet paper. Check blankets for urine/fluids and change only if necessary
    • Force feed patients after anti-emetic medications have had time to take effect (30 minutes if SQ, 15 if IV)
    • Flush catheter with Heparin flush. Check IV bag to ensure there is enough fluids until the next shift. Check fluid rate and VTBI.
    • Fill out the medical chart for the correct shift!
    • Wash hands between patients
  5. Check/continue laundry throughout shift
  6. Double check all charts to ensure all patients have been treated fully
  7. Carefully restore medications, ensuring that refrigerated meds are stored properly 
  8. Double check all patients have enough fluids in their IV bags, all pumps are set to mL/hr, sufficiently set VTBIs/Preset (reset the amount accumulated)
  9. Fill and send the End Of Shift Parvo Report 
  10. Clean the ICU - dishes, wipe down counters, fold laundry, sweep 
  11. Turn off the drier (this is a fire hazard)
  12. Wash hands and exit ICU following proper quarantine protocols 

End of Day 4 Quiz

  1. Which type of mange is contagious?
  2. When does a bag of LRS with 5% Dextrose expire?
  3. An LRS bag used for SQ fluids is strored, but the last volunteer forgot to put a cap on the needle. Are the fluids sterile anymore? Why/why not?
  4. What are the two causes of death from parvovirus?
  5. What route is Polyflex given?
  6. What are 4 reasons the IV Pump might be beeping?

Day 5 - Specific and Additional Protocols

At this point, you should be able to verbally explain the importance of all primary drugs administered as well as all the details of their administration to your trainer. You should be capable of performing 90% of treatments on your own. . We still want you to be comfortable with asking questions to your co-volunteers and doctors if you're ever not sure of something. Remember, you should never inject anything into a patient if you don't know what it is and what adverse side effects could result if used improperly.

New Protocols

  • Crashing Puppy Protocol - Its imperative to be familiar with this information so you'll be prepared in an emergency situation. A few minutes can be the difference between life and death for a crashing puppy.
  • SNAP Parvo test - The IDEXX SNAP test is used to determine if a recovered patient is no longer spreading the disease and is therefore safe to come out of Isolation

Efficiency Goals

During peak parvo season in the spring and early summer, (depending on geographical location), the Parvo ICU can have 30+ patients. All volunteers must go into "triage mode" to treat all dogs in a timely manner such that shifts do not last longer than 4 hours. One efficient volunteer is often more valuable than two or three slower volunteers. The following are triaging/efficiency goals for when we have 15+ dogs.

 Treatment(tx) TypeMAX Time (min)
 PO tx 5
 SQ tx 15
 IV tx 15
 IV w/ pump problems 20
 IV tx w/ catheter problems 25
 IV tx w/ new IVC placement 35

Review these tips for efficiency on the Triage Mode page!

Shift Structure

Quiz yourself! Walk through the main shift tasks and compare them to the following example:
  1. Enter the ICU following proper quarantine protocols
  2. Start of Shift Responsibilities
    1.  Do a quick walk-through the entire ICU to look at all patients and determine who is the most critical. Some patients may need emergency treatment if unresponsive during the walk-through
    2. Start the laundry - every volunteer and staff member is needed to keep the ICU clean and organized
  3. Pick 2-3 medical charts at a time, starting with the critical patients, and start drawing up meds for multiple patients
  4. Treat patients
    • Check gums, paws, and for edema (fluid that hasn't been absorbed from last SQ treatment)
    • Check catheter for patency and swelling
    • Administer medications
    • Offer a meatball size amount of food to patients. If showing signs of nausea, remove food from cage. Replace water bowl
    • Remove any solid materials from blankets with toilet paper. Check blankets for urine/fluids and change only if necessary
    • Force feed patients after anti-emetic medications have had time to take effect (30 minutes if SQ, 15 if IV)
    • Flush catheter with Heparin flush. Check IV bag to ensure there is enough fluids until the next shift. Check fluid rate and VTBI.
    • Fill out the medical chart for the correct shift!
    • Wash hands between patients
  5. Check/continue laundry throughout shift
  6. Double check all charts to ensure all patients have been treated fully
  7. Carefully restore medications, ensuring that refrigerated meds are stored properly 
  8. Double check all patients have enough fluids in their IV bags, all pumps are set to mL/hr, sufficiently set VTBIs/Preset (reset the amount accumulated)
  9. Fill and send the End Of Shift Parvo Report
  10. Clean the ICU - dishes, wipe down counters, fold laundry, sweep 
  11. Turn off the drier (this is a fire hazard)
  12. Wash hands and exit ICU following proper quarantine protocols 

End of Day 5 Quiz

Name 3 strategies you'll use when there are 10+ dogs in the ICU
What are the signs/symptoms that indicate a puppy is crashing?

Day 6 - Wrapping It Up

Efficiency Goals

Continue to work on your efficiency for the next several weeks!

 Treatment(tx) TypeMAX Time (min)
 PO tx 5
 SQ tx 15
 IV tx 15
 IV w/ pump problems 20
 IV tx w/ catheter problems 25
 IV tx w/ new IVC placement 35

Review these tips for efficiency on the Triage Mode page!

Team Guidelines

  • Signing up for shifts is a serious commitment and should be treated as such. The integrity of the Parvo Program depends on reliable volunteers. Be aware of the rules and consequences for Missing a Shift that you're scheduled for. Cancelling a shift should not be a common occurence, and cancelling a shift last minute is unacceptable unless its an emergency.
  • Be aware of the requirements to Stay Active as a volunteer
  • If a puppy seems to be in any amount pain, call/text the doctor. They are likely to prescribe pain medications.
  • Consult the Medicine Chart posted in the Parvo ICU if you are unfamiliar with a medication. Do not be afraid to ask your co-volunteer questions as well!
  • Have the veterinarians' and manager's phone number stored in your phone.
  • Keep the ICU Clean!

Other Protocols

The following protocols where not covered in the previous days' material. You do not need to read through the all, just be aware that you can reference these protocols while in the ICU when needed:

End of Training Test

Trainee Test


Please email the parvo manager at and let them know the test has been completed so they can check your answers. Feel free to use the wiki, but most of these answers you should already know.
ĉ
Nipuni Ratnayaka,
Jan 4, 2015, 7:49 PM