2019 SLAOTI/POSNA TF - Final Day in Curitiba - Day 4

Today was a peds ortho-filled day in Curitiba!  We started the morning bright and early.  After enjoying our daily breakfast bonding session we were picked up by Bruno, one of the pediatric orthopaedic fellows from Hospital Pequeno Príncipe (HPP), and we walked the 2 blocks over to the hospital.  We started the morning in spine clinic, but they were kind enough to throw in a few trauma and “superior extremity” patients for Coleen and Apurva.  Apurva evaluated an 8-year-old boy with ulnar longitudinal dysplasia and a 13-month-old boy with brachial plexus birth injury.  We had a discussion regarding the potential benefits of botulinum injection and closed reduction of the shoulder and spica casting. 


Coleen discussed reduction and pinning techniques for supracondylar humerus fractures with a group of fellows and residents. 

We also spent some time with Dulce Helena Grimm who is one of the many female orthopedic surgeons in Brazil (Brazil has a higher percentage of female orthopaedic surgeons than we do in the US) and had been the first female orthopedic resident at HPP years ago.  Dr. Grimm has been on faculty at HPP for years and we were told by the other faculty that she rounds morning and night on the patients with the residents every day – she is admirably committed to patient care and resident education!

In clinic, we were also able to spend some time discussing patients with Ana Laura Munhoz da Cunha, João Caetano Munhoz Abdo, and Alencar Kenji Nagai.
The spine team at HPP includes Luis Eduardo Munhoz da Rocha, Carlos Abreu de Aguiar and Luiz Müller Avila.  All three surgeons were extremely knowledgeable and had developed close relationships with their long-term patients.  Some of the particularly interesting and complicated children included an 11-year-old girl with spondyloptosis, a 16-year-old girl with dystonia and spinal deformity causing severe trunk shift, and a number of patients with multiple congenital abnormalities causing severe acute and rigid deformities.  The patients seemed extremely grateful to have been treated at HPP and had such positive things to say about their experiences. After clinic, we rounded with the team on some post-operative spine patients and had a tour of the hospital at the same time.  We saw a teenage boy who was treated with a T2 to L2 posterior instrumented spinal fusion for Scheuremann’s kyphosis and a five year old boy who was being treated with halo gravity traction for a severe kyphoscoliosis.


We concluded our visit to HPP with some parting pictures with the HPP team and said our good-byes to many new friends.


Carolina (pediatric orthopedic fellow) from Hospital do Trabalhador picked us and we made a quick stop at a favorite lunch spot of theirs before heading to Monday afternoon general pediatric orthopaedic clinic at the Hospital do Trabalhador.  This clinic is staffed by a big team of residents and fellows from various programs in the city along with three attending physicians.  For those that may not be familiar, typical orthopaedic surgery training in Brazil includes 4 years of University/Medical School (right after high school), 3 years of residency training and 1-2 years of fellowship training. 
In the general pediatric clinic at Hospital do Trabalhador, the team evaluates between 130 and 200 patients in one four-hour afternoon session on Mondays.  Patients arrive at block intervals and are seen based on age and acuity.  Today, two senior pediatric orthopaedic surgeons, Dr. Jamil Soni and Dr. Weverley Valenza, led the clinic and hosted our visit.  They were also joined by Dr. Fernando Faria.  Coleen had the opportunity to discuss with the team the evaluation and treatment options for a 16-year-old male with a recurrent clubfoot and also review some finer points in clubfoot casting techniques.  Salil had an opportunity to assess a baby with an Ortolani-positive hip for whom a Pavlik harness was started as well as 23-year-old female with residual hip deformity and acetabular dysplasia following a relative neck lengthening for Perthes.  Apurva helped in the assessment of a 8-year-old boy with bilateral congenital radioulnar synostosis with a 105° hyperpronation position on the left.  He discussed derotation osteotomy techniques with an orthopaedic surgery resident and Dr. Valenza.

We had the unique opportunity to meet with the General Director of the hospital, Dr. Geci Labres de Souza, and Dr. Marcia Luiza Krajden the Technical Director of the hospital, and we had an extensive tour of the facilities, which were very comprehensive.  As a tertiary care trauma center, the hospital is well equipped to accept major polytraumatic injuries requiring rapid resuscitation or emergent surgical stabilization.  We appreciate the warm welcome we received from the administraton at Hospital do Trabalhador!

We wrapped up our time at Hospital do Trabalhador with some additional discussion with Drs. Soni and Valenza about how they maintain their enthusiastic energy and commitment to providing the highest level of care possible to people from all socioeconomic levels in Curitiba and surrounding areas.

After a busy day, we had a final dinner with the father-daughter team of Professor Luiz Antonio Munhoz da Cunha (Chair of Orthopaedic Surgery at HPP) and his daughter Ana Laura Munhoz da Cunha, also an HPP orthopaedic surgeon.  Over dinner, we introduced Dr. Munhoz da Cunha to his first Negroni, reflected upon our stay in Curitiba and then turned in early as we needed to depart before dawn for Buenos Aires. 
We are so grateful for the hospitality we received in Curitiba from our Brazilian colleagues, and excited about the bonds of friendship that we will carry forward.   We are incredibly thankful for the amazing hospitality that we were shown by the pediatric orthopaedic surgeons in Curitiba - Thank you for a phenomenal visit!
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